DIGESTIVE 

ORGANS Bacillus lactis may be found where the child is bottle fed . If there is trouble with the first dentition and food is allowed to collect, staphylococci, streptococci, pneumococci and colon bacilli may be present . Even in healthy babies Oidium albicans may be present, and in older children the pseudo-diphtheria bacillus . From carious teeth may be isolated streptothrix, leptothrix, spirilla and fusiform bacilli . Under conditions of health these micro-organisms live in the mouth as saprophytes, and show no virulence when cultivated and injected into animals . The two common pyogenetic organ-isms, Staphylococcus albus and brevis, show no virulence . Also the pneumococcus, though often present, must be raised in virulence before it can produce untoward results . The foulness of the mouth is supposed to be due to the colon bacillus and its allies, but those obtained from the mouth are in-nocuous . Also to enable the Oidium albicans to attack the mucous membrane there must be some slight inflammation or injury . The micro-organisms found in the stomach gain access to that organ in the food or by regurgitation from the small intestine . Most are relatively inert, but some have a special fermentative action on the food (see NUTRITION) . Abelous isolated six-teen distinct species of organism from a healthy stomach, including Sarcinae, B. lactis, pyocyaneus, subtilis, lactis erythrogenes, amylobacter, megatherium, and Vibrio rugula .

Hare-lip, cleft palate, hernia and imperforate anus are physical abnormalities which are interesting to the surgeon rather than to the pathologist . The oesophagus may be the seat of a diverticulum, or blind pouch, usually situated in its lower half, which in most instances is probably partly acquired and partly congenital; a local weaknesa succumbing to pressure . Physical Hypertrophy of the muscular coat of the pyloric region abnormatltlrs . is an infrequent congenital gastric anomaly in infants, preventing the passage of food into the bowel, and causing death in a short time . Incomplete closure of the vitelline duct results in the presence of a diverticulum-Meckel's-generally connected with the ileum, mainly important by reason of the readiness with which it occasions intestinal obstruction . Idiopathic congenital dilatation of the colon has been described . Traction diverticula of the oeso- phagus not uncommonly occur as sequels to suppurative inflamma- tion of cervical lymphatic glands . More frequently dilatation of a section is met with, due as a rule to the presence of a stricture . The stomach often diverges from the normal in size, shape and position . Normally capable in the adult of containing from fifty to sixty ounces, either by reason of organic disease, or as the result of functional disturb- ance, its capacity may vary enormously . The writer has seen post mortem a stomach which held a gallon (16o ounces), and again one holding only two ounces . Cancer spread over a large area and cirrhosis of the stomach wall cause diminution in capacity; pyloric obstruction, weakness of the muscular coat, and nervous influences are associated with dilatation .

A

peculiar distortion of the shape of the stomach follows cicatrization of Numbers of bacterial forms habitually infest the alimentary canal . Many of them are non-pathogenic; some develop patho- genic characters only under provocation or when a suitable environment induces them to act in such a manner; others may form the materies morbi of special lesions, or be casual visitors capable of originating disease if opportunity occurs . Apart from those organisms associated with acute infective diseases, disturbances of function and physical Vegetable parasites . Males . Females . Both Sexes . Organ or Tissue in Per- Organ or Tissue in Per- Organ or Tissue in Per- Order of Frequency. centage . Order of Frequency. centage . Order of Frequency. centage . I Stomach . 22.56 I Stomach . . 22.37 I Stomach .

. 22.49 2 Lip . 12.94 2 Rectum 17.24 2 Rectum 13.I2 3 Rectum . . II.57 3

Liver . . . 15.50 3 Liver 10.02 4 Tongue . . 11.36 4 Peritoneum 7.86 4 Lip 9.89 5 Oesophagus 10.90 5 Oesophagus 5'33 5 Oesophagus 9.29 6 Liver . . 7.80 6 Sigmoid 4.53 6 Tongue 8.96 7 Jaw 6.38 7 Pancreas . . 3.52 7 Jaw . . . . 5.65 8 Mouth . . 2.88 8 Tongue . . .

3.12 8 Peritoneum 2.94 9 Tonsils 2.09 9 Omentum . . 2,98 9 Sigmoid . . 2.56 10 Sigmoid flexure 1.77 10 Lip . . . . 2.57 Ia Mouth . . . 2.40 II Parotid II Jaw . 1.97 I1 Pancreas 1.80 12 Pancreas I 10 12 Colon . . 12 Tonsils . . . 1.35 13 Caecum . 1 13

Abdomen .

1'84 13 Omentum . 1.25 14 Peritoneum . 0.94 14 Intestine . . 1.56 14 Parotid . 15 Colon . 0.89 15 Caecum 1.37 15 Colon 1.12 16 Pharynx . . 16 Mouth . . . 1 18 16 Caecum 1.08 17 Intestine (site 0.79 17 Parotid 17 Intestine unknown) . 18 Splenic flexure o•98 18 Abdomen . I'oo 18 Abdomen . . 0.71 19 Jejunum and 19 Pharynx .

. 0.62 19 Mesentery ileum . . . 0.78 20 Mesentery 0.52 20 Omentum . 0.55 20 Tonsils . 0.68 21 Jejunum and 21 Hepatic flexure o•39 21 Pharynx . . l 0.40 ileum . - • 0.44 22 Submaxillary . 22 Hepatic flyexure 22 Hepatic flexure

land . 0.31 23 0'20 23 Slenic o•28 23 Jeju num and 24 Submaxillary 24 Submaxllarye . ileum . . 25 Duodenum . 25 Duodenum 0.22 24 Duodenum .

. 0.23 25 Splenic flexure 0.15

Note.-The figures where several organs are bracketed apply to each organ separately . lesions may be the result of abnormal bacterial activity in the canal; and these disturbances may be both local and general . Many of the bacteria commonly present produce putrefactive changes in the contents of the tract by their metabolic processes . They render the medium they grow in alkaline, produce different gases and elaborate more or less virulent toxins . Other species set up an acid fermentation, seldom accompanied by gas or toxin formation . The products of either class are inimical to the free Per- Per- Per- Males. centage . Females . centage . tentage.• Total . i Mouth and I Intestines 28.9 1 Oesophagus and pharynx . 37.85 2 Oesophagus and stomach 31.78 2 Oesophagus and stomach 27.7 2 Mouth a n d stomach . . 33.46 , 3 Liver 15.5 pharynx .

. 30'27 3 Intestines 17.04 4 Peritoneum . 13.1 3 Intestines . . 20.42 4Liver . 7.8 5Mouth and • 4Liver . . . 10.02 5 Peritoneum . . 2.75 pharynx . 11.3 5 Peritoneum . . 5.71 6 Pancreas 1.1 6 Pancreas 3.5 6 Pancreas 1.8o growth of members of the other . The specieswhich produce acids are more resistant to the action of acids . Thus, when the contents of the stomach possess a normal or excessive proportion of free hydrochloric acid, a much larger number of putrefactive and pathogenic organisms in the food are destroyed or inhibited than of the bacteria of acid fermentation . Diminished gastric acidity allows of the entry of a greater number of putrefactive (and pathogenic) types, with, as a consequence, increased facilities for their growth and activity, and the

appearance of intestinal derangements .

In a healthy new-

born infant the mouth is free from micro-organisms, and very few are found in a breast-fed baby, but ulcers of greater or lesser curvature; the gastric cavity becomes " hour-glass " in shape . In addition, the stomach may be displaced downwards as a whole, a condition known as gastroptosis: if the pyloric portion only be displaced, the lesion is termed pyloroptosis . Ptoses of other abdominal organs are described; the liver, transverse colon, spleen and kidneys may be involved . Displacements downwards of the stomach and transverse colon, along with a movable right kidney and associated with dyspepsia and neurasthenia, form the malady termed by Glenard enteroptosis . A general visceroptosis often occurs in those patients who have some tuberculous lesion of the lungs or elsewhere, this disease causing a general weakening and subsequent stretching of all ligaments . Displacements of the abdominal viscera ate almost invariably accompanied by symptoms of dyspepsia of a neurotic type . The rectum is liable to prolapse, consequent upon constipation and straining at stool, or following local injuries of the perineal floor . Every pathological lesion shown by digestive organs is closely associated with the state of the nervous system, general or local; Influence so stoppage of active gastric digestive processes after oftee profound nervous shock, and occurrence of nervous nervous diarrhoea from the same cause . Gastric dyspepsia system. of nervous origin presents most varied and contradictory symptoms: diminished acidity of the gastric juice, hyper-acidity, over-production, arrest of secretion, lessened or increased movements, greater sensitiveness to the presence of contents, dilatation or spasm . Often the nervous cause can be traced back farther,—in females, frequently to the pelvic organs; in both sexes, to the condition of the blood, the brain or the bowel . Unhealthy conditions related to evacuation of the bowel-contents commonly induce reflex nervous manifestations of abnormal character referred to the stomach and liver . Gastric disturbances similarly react upon the proper conduct of intestinal functions .

Local Diseases . The Mouth.—The lining membrane of the cheeks inside the mouth, of the gums and the under-

surface and edges of the tongue, is often the seat of small irritable ulcers, usually associated with some digestive derangement . A crop of minute vesicles known as Koplik's spots over these parts has been lately stated by Koplik to be an early symptom of measles . Xerostomia, or dry mouth, is a rare condition, connected with lack of salivary secretion . Gangrenous stomatitis, cancrum oris, or noma, occasionally attacks debilitated children, or patients convalescing from acute fevers, more especially after measles . It commences in the gums or cheeks, and causes widespread sloughing of the adjacent soft parts—it may be of the bones . The Stomach.—It were futile to attempt to enumerate all the protean manifestations of disturbance which proceed from a disordered stomach . The possible permutations and combinations of the causes of gastric vagaries almost reach infinity . Idiosyncrasy, past and present gastric education, penury or plethora, actual digestive power, motility, bodily requirements and conditions, environment, mental influences, local or adjacent organic lesions, and, not least, reflex impressions from other organs, all contribute to the variance . Ulcer of the stomach, however—the perforating gastric ulcer —occupies a unique position among diseases of this organ . Gastric ulcers are circumscribed, punched out, rarely larger than a sixpenny-bit, funnel-shaped, the narrower end towards the peritoneal coat, and distributed in those regions of the stomach wall which are most exposed to the action of the gastric contents . They occur most frequently in females, especially if anaemic, and are usually accompanied by excess of acid, actual or relative to the state of the blood, in the stomach contents .

Local

pain, dorsal pain, generally to the left of the eighth or ninth dorsal spinous process, and haematemesis and melaena, are symptomatic of it . The amount of blood lost varies with the rapidity of ulcer formation and the size of vessel opened into . Fatal results arise from ulceration into large blood-vessels, followed by copious haemorrhage, or by perforation of the ulcer into the peritonealcavity . Scars of such ulcers maybe found post mortem, although no symptoms of gastric disease have been exhibited during life; gastric ulcers, therefore, may be latent . Irritation of the sensory nerve-endings in the stomach wall from the presence of an increased proportion of acid, organic or mineral, in the stomach contents is accountable for the well-known symptom heartburn . Water-brash is a term applied to eructation of a colourless, almost tasteless fluid, probably saliva, which has collected in the lower part of the oesophagus from failure of the cardiac sphincter of the stomach to relax; reversed oesophageal peristalsis causing regurgitation . A similar reversed action serves in merycism, or rumination, occasionally found in man, to raise part of the food, lately ingested, from the stomach to the mouth . Vomiting also is aided by reversed peristaltic action, both of the stomach and the oesophagus, with the help of the diaphragm and the muscles of the anterior abdominal wall . Emesis may be caused both by local nervous influence, and through the central nervous mechanism either reflexly or from the direct action of substances circulating in the blood . Further, the causal agent acting on the central nervous apparatus may be organic or functional, as well as medicinal . Vomiting without any apparent cause suggests nervous lesions, organic or reflex . The obstinate vomiting of pregnancy is a case in point .

Here the

primary cause proceeds reflexly from the pelvis . In females the pelvic organs are often the true source of emesis . Haematemesis accompanies gastric ulcer, cancer, chronic congestion with haemorrhagic erosion, congestion of the liver, or may follow violent acts of vomiting . In cases of ulcer the blood is usually bright and in considerable amount; in cancer, darker, like coffee-grounds; and in cases of erosion, in smaller quantity and of bright colour . The reaction of the stomach contents, if the cause be doubtful, yields valuable aid towards a diagnosis . Of increased acidity in gastric ulcer, normal in hepatic congestion, it is diminished in cancer; but as the acid present in cancer is largely lactic, analysis of the gastric contents must often be a sine qua non, because hyperacidity from lactic may obscure hypoacidity of hydrochloric acid . Flatulence usually results from fermentative processes in the stomach and bowel, as the outcome of bacterial activity . A. different form of flatulence is common in neurotic individuals; in such the gas evolved consists simply in carbonic acid liberated from the blood, and its evolution is generally characterized by rapid development and by lack of all fermentative signs . The Liver.—The liver is an organ frequently libelled for the delinquencies of other organs, and regarded as a common source of ill . In catarrhal jaundice it is in most cases the bowel that is at fault, the liver acting properly, but unable to get rid of all the bile produced . The liver suffers, however, from several diseases of its own . Its fibrous or connective tissue is very apt to increase at the expense of the cellular elements, destroying their functions .

This cirrhotic process usually follows

long-continued irritation, such as is produced by too much alcohol absorbed from the bowel habitually, the organ gradually becoming harder in texture and smaller in bulk . Hypertrophic cirrhosis of the liver is not uncommonly met with, in which the liver is much increased in size, the " unilobular form, also of alcoholic origin . In still-born children and in some infants a form of hypertrophic cirrhosis is occasionally seen, probably of hereditary syphilitic origin . Acute congestion of the liver forms an important symptom of malarial fever, and often leads in time to establishment of cirrhotic changes; here the liver is generally enlarged, but not invariably so, and the part played by alcohol in its causation has still to be investigated . Acute yellow atrophy of the liver is a disease sui generic . Of rare occurrence, possibly of toxic origin, it is marked by jaundice, at first of usual type, later becoming most intense; by vomiting; haemorrhages widely distributed; rapid diminution in the size of the liver; the appearance of leucin and tyrosin in the urine, with lessened urea; and in two or three days, death . The liver after death is soft, of a reddish colour dotted with yellow patches, and weighs only about a third part of the normal—about r~ lb in place of 3; lb . A closely analogous affection of the liver, known as Weil's disease, is of infectious type, and has been noted in epidemic form . In this the spleen and liver are commonly but not always swollen, and the liver is often tender on pressure . As a large proportion of the sufferers from this disease have been butchers, and the epidemics have occurred in the hot season of the year, it probably arises from contact with decomposing animal matter . Hepatic abscess may follow on an attack of amoebic dysentery, and is produced either by infection through the portal vein, or by direct infection from the adjacent colon . In general pyaemia multiple small abscesses may occur in the liver .

The

Gall-Bladder.--The formation of biliary calculi in the gall-bladder is the chief point of interest here . At least 75% of such cases occur in women, especially in those who have borne children . Tight-lacing has been stated to act as an exciting cause, owing to the consequent retardation of the flow of bile . Gall-stones may number from one to many thousands . They are largely composed of cholesterin, combined with small amounts of bile-pigments and acids, lime and magnesium salts . Their presence may give rise to no symptoms, or may cause violent biliary colic, and, if the bile-stream be obstructed, to jaundice . Inflammatory processes may be initiated in the gall-bladder or the bile-ducts, catarrhal or suppurative in character . The Pancreas.—Haemorrhages into the body of the pancreas, acute and chronic inflammation, calculi, cysts and tumours, among which cancer is by far the most common, are recognized as occurring in this organ; the point of greatest interest regarding them lies in the relations established between pancreatic disease and diabetes mellitus, affections of the gland frequently being complicated by, and probably causing, the appearance of sugar in the urine . The Small Intestine.—Little remains to be added to the account of inflammatory lesions in connexion with the small intestine . It offers but few conditions peculiar to itself, save in typhoid fever, and the ease with which it contrives to become kinked, or intussuscepted, producing obstruction, or to take part in hernial protrusions . The first section, the duodenum, is subject to development of ulcers very similar to those of the gastric mucous membrane . For long duodenal ulceration has been regarded as a complication of extensive burns of the skin, but the relationship between them has not yet been quite satisfactorily explained .

The condition of colic in the bowel usually arises from over distension of some part of the small gut with gas, the frequent

sharp turns of the gut facilitating temporary closure of its lumen by pressure of the dilated gut near a curve against the part beyond . In the large bowel accumulations of gas seldom cause such acute symptoms, having a readier exit . The Large Intestine.—The colon, especially the ascending portion, may become immensely dilated, usually after prolonged constipation and paralysis of the gut; occasionally the condition is congenital . Straining efforts made in defaecation may often account for prolapse of the lower end of the rectum through the anus . Haemorrhage from the bowel is usually a sign of disease situated in the large intestine: if bright in colour, the source is probably low down; if dark, from the caecum or from above the ileo-caecal valve . Blood after a short stay in any section of the alimentary canal darkens, and eventually becomes almost black in colour . (A . L . G.; M .