after a push or blow upon the abdomen (Volz), heavy lifting
(Volperling), riding in a wagon (Marsh), after dancing (Cless), mere
turning of the body in bed (Langdon Downs), after emesis (Urban),
purgation (Stokes), enema (Mêlier), etc., etc. That the slightest
agitation may suffice at times to break down the last barrier of serous
tissue separating the intestinal and peritoneal cavity is shown in the
case recorded by With, where fatal perforative peritonitis occurred
after a fit of immoderate laughter.
Paratyphlitis distinguishes itself from the other forms of the disease
by its more insidious character. There is also in paratyphlitis, as a
rule, less disturbance in the alimentary canal. The cæcum in
paratyphlitis is mostly empty or is filled with gas, whose presence is
recognized by tympanitic resonance on lighter percussion. On the other
hand, paratyphlitis is characterized by the greater frequency of
pressure signs in the right lower extremity. If the subjacent iliac and
psoas muscles be implicated, the thigh is flexed upon the leg in
decubitus. Various paræsthesiæ, formication, numbness, pain, and
veritable paresis are experienced in the right leg. Dysuria, retraction
of the testicle, and priapism may also occur in this form of the
disease. Or pressure upon the iliac vein {820} induces thrombosis, with
oedema, milk leg. The long-continued process of suppuration in
paratyphlitis leads also at times to hectic fever or pyæmia, with slow
marasmus.
In all cases relapses are very frequent, as repeated occurrences of the
disease constitute the rule. Eichhorst records the case of a
court-officer who suffered five attacks of paratyphlitis in the short
space of one and a half years.
DIAGNOSIS.--The recognition of the disease is mostly simple. The pain,
the tumor, and the disturbances of digestion sufficiently, and for the
most part sufficiently early, distinguish the affection.
Simple impaction of feces is differentiated by the history of
constipation; by the feel of the hardened feces, which form an
elongated, nodulated, sausage-shaped tumor along the entire ascending
colon, and later in shifting along the transverse colon; by the
comparatively slight tenderness; and by the entire relief which follows
thorough irrigation of the bowel.
Cancer may be eliminated by regard of the age of the patient, the slow
development and course of the symptoms, and the gradual manifestation
of its cachexia.
Invagination is an affection for the most part of early childhood--is
marked by the sudden appearance of violent symptoms of disturbance of
digestion, vomiting, often stercoraceous, occlusion, diarrhoea, or
dysentery, with straining and discharges of blood.
DURATION.--Typhlitis and its complications have no definite duration. A
case may terminate fatally in the course of a few days or may extend
itself over months, or with its effects over years or for life. The
disease is, as a rule, much shorter in childhood than in adult life.
According to Matterstock, nearly one-half (44 per cent.) of children
succumb to the disease within the first three days. Wood records the
case of a girl aged ten who died in nine hours. The average duration of
cases of typhlitis without suppuration ranges from fourteen to
twenty-one days. The early evacuation of inflammatory products by
aspiration or incision may cut the disease short at any time, or
exacerbations and remissions may manifest themselves for months or
years--a condition especially liable to occur when burrowing sinuses or
fistulæ develop, or when passive encapsulated abscesses are aroused
into activity by some accident or indiscretion on the part of the
patient.
PROGNOSIS.--A case of typhlitis stercoralis has no gravity, and should
terminate or be terminated within twenty-four to forty-eight hours
after its recognition. Neglected or unrecognized cases, however, are
not infrequently fatal from the circumscribed or more especially
diffuse peritonitis which may ensue.
Typhlitis independent of fecal impaction is always a grave affection,
requiring in every instance a very guarded prognosis.
Every form of typhlitis is more fatal in childhood than in adult life,
and any case of the disease may present grave complications or assume a
dangerous form at any time. The greater danger of childhood lies in the
greater liability to peritonitis. Most subsequent writers confirm this
statement, first made by Willard Parker, who also remarked that
suppurative processes, abscess formation, is more common in the adult.
The mortality of perityphlitis alone in childhood is 70 per cent., in
adult life 30 per {821} cent., so that the proportion of recoveries is
exactly the reverse of these figures at the different periods of life.
The general adoption of the opium treatment has, however, rendered the
prognosis of typhlitis far more favorable--has, in fact, reduced the
mortality in adult life from 80 per cent., the appalling figures of the
older statistics (Volz), to 30 per cent., the ratio of modern times.
The means of earlier detection and readier relief of accumulated pus
have also contributed much to reduce the mortality of typhlitis. In
1872, Bull of New York had to report of 67 cases of perityphlitic
abscess collected by him, mostly treated without operation, a mortality
of 47½ per cent., while ten years later (1882) Noyes of Providence was
able to report of 100 cases treated by operation a mortality of only 15
percent. (Pepper[7]).
[Footnote 7: "Contribution to the Clinical Study of Typhlitis, etc.,"
_Trans. Med. Soc. Penna._, 1883.]
The development of fistulæ or wandering abscess, the occurrence of
pyæmia and peritonitis, necessarily aggravate the prognosis of a simple
case. Perforation is fatal of necessity, yet cases are not wanting
where recovery has occurred even after this gravest of all the
accidents of the disease. Thus, Patschkrowski reports, from Frerichs'
clinic, a case of recovery after perforation, and Pepper mentions the
results of an autopsy made upon an old man who died of vesical
hemorrhage, in whom he "found that there had, at some unknown previous
time, been perforation of the appendix."
PROPHYLAXIS.--The prevention of typhlitis has reference more especially
to cases of habitual recurrence of the disease in adults, or to the
earliest, prodromatous, stage in childhood. The slightest manifestation
of pain in the right iliac region should be looked upon with suspicion
in these cases, and absolute rest enjoined at once. Since in childhood
perforation has occurred in insidious cases after so slight an
irritation as a laxative or an enema, or even after a bath, every
provocation of this kind should be avoided. Injunction is to be put
upon all solid food in all cases in the inception as well as throughout
the course of the affection, that the element of coprostasis be not
superadded to the irritation of the disease. Adults subject to frequent
recurrences or relapses will thus avoid also the development or
aggravation of an intestinal catarrh, which in other cases of trivial
import may become dangerous to them. Many cases of typhlitis are
doubtless aborted at the start by the observance of absolute rest and
abstinence from food or rigid diet at the start.
TREATMENT.--Perhaps no disease requires such careful consideration of
its cause or form, inasmuch as the different varieties call for
entirely different treatment. A typhlitis stercoralis, for instance,
requires an exclusive evacuant treatment, whereas a peri- or
paratyphlitis demands a treatment that shall put the bowels at rest.
The safest and most effective method of emptying the cæcum of impacted
feces is by irrigation of the bowels by means of the funnel syringe
devised by Hegar. The patient is put in the knee, elbow, or chest
posture, and warm water--which is the best solvent for hardened
feces--is allowed to slowly inundate the whole tract of the colon,
after the manner and with the precautions already pointed out in the
article on dysentery. Feeble or reduced patients should be supported in
this posture until as much water as possible is slowly introduced. As a
rule, a single thorough irrigation will suffice, or one or several
additional operations may be required {822} to secure the desired
effect. At the same time, broken doses, twenty grains, of sulphate of
magnesia may be administered every hour or two, not so much for the
purpose of exciting additional peristalsis as of turning water into the
intestinal canal from above.
The other varieties of the affection call for opium at the start, with
the double view of preventing the irregular, spasmodic, or tetanic
contraction of the muscular coat and of obviating the danger of
peritonitis. Opium is not contraindicated in these cases, even if the
element of fecal impaction be superadded, as all clinicians are
familiar with the fact that the bowels will move of themselves at times
even under its full narcotic effects.
The remedy is best given in fluid form, as in the tincture, that the
dose may be graduated in its repetition to secure its full effect
without danger. When a quick action is required, morphia hypodermically
may be preferred; yet it is to be remembered that opium with all its
active principles is of more value in the relief of peritonitis than
morphia alone. A careful watch should be kept upon all patients treated
with large or frequently-repeated doses of opium, that its toxic
effects be avoided. Not infrequently symptoms of poisoning have
supervened after a sudden relief of pain, necessitating the use of
means to keep the patient awake for a number of hours.
Hot embrocations, or poultices applied over large surfaces of the
abdomen, give great comfort to the patient, though the very opposite
treatment of an ice-bag, occasionally shifted or suspended, is more
agreeable in some cases in the inception of the disease.
So soon as a distinct doughy sensation or a more marked fluctuation
indicates the development of pus, steps should be undertaken at once to
secure its evacuation. In cases of doubt it is best to make a tentative
exploration with the needle of the aspirator, a large-sized needle
being preferred on account of the liability of occlusion with
tissue-shreds or other débris. It is quite surprising how rapidly a
case clears up at times after the evacuation of even only a drachm or
two of oedematous fluid. More frequently, however, the aspiration must
be repeated until a quantity of pus is secured and the abscess
completely discharged.
An abscess of more superficial situation, of larger size, or of
continuous formation is best relieved by free incision. As to the time
of the operation, the old rule, ubi pus ibi incisio, holds good here as
elsewhere. An early evacuation of the products of inflammation prevents
the supreme danger of perforative peritonitis or the formation of
burrowing sinuses, fistulæ, amyloid degeneration, and marasmus.
Indurated tumors are sometimes made to soften under the long-continued
use of cataplasms, and chronic thickenings of the walls of the
intestine are relieved by general tonics, mild laxatives, mineral
waters, and gentle frictions with iodine or mercurial ointments.
Perforative peritonitis calls for opium in maximum doses as a means of
facilitating possible agglutinations or encapsulations, and a forlorn
hope is offered in an early laparotomy, which the bolder surgeons are
now undertaking in the equally desperate cases of perforation by gall-
or kidney-stones, etc.
Under no circumstances should a patient affected with typhlitis leave
the bed until the last trace of inflammation has subsided, as in no
disease is there greater liability to recurrence or relapse.
{823}
INTESTINAL ULCER.
BY JAMES T. WHITTAKER, M.D.
Intestinal ulcer, Ulcus intestinorum entero-helcosis ([Greek:
helchôsis], ulcer), represents a solution of continuity in the wall of
the intestine, affecting first, as a rule, its mucous coat. Ulcer of
the intestine, like ulcer of the stomach, its occasional congener and
not infrequent associate, is the expression of an insult or injury
offered to the intestinal coat in its inner exposed surface, or of a
necrobiosis the result of a local occlusion in the general
blood-supply. Hence, ulcer of the intestine may be a purely local
disease, or be the local expression of a general, so-called
constitutional, disease. While in many cases the lines differentiating
these conditions may not be distinctly drawn, as many so-called
constitutional conditions (tuberculosis, typhoid fever, etc.) are
discovered to be--at first, at least--local processes, the toxic ulcer
(arsenic, mineral acids) may be taken as a type of the local process,
acting from within, and the syphilitic ulcer as the type of the general
process, acting from without. At the same time, it must be recognized
of syphilis that an ulcer may result from the dissolution or breaking
down of a gummatous mass anywhere in the course of the intestine, or
may be the effect of infection by extension into the rectum of
syphilitic processes about the genital organs, or, lastly, of direct
introduction of the disease in perverted intercourse (pederasty, coitus
heterotopicus).
Ulcer of the intestine is occasionally, though comparatively very
rarely, observed also as the result of pressure from within or without.
Such an ulcer is properly considered of traumatic or mechanical origin,
as it is induced as the direct effect of mechanical irritation or
arrest of blood-supply. Thus, dense masses of inspissated feces,
foreign bodies, indigestible residue of food, may fret the mucous
surface into a condition of hyperæmia, and, later, absolute ulceration.
Undue retention, as behind a cicatricial contraction, or an occlusion
from whatever cause at places where the intestinal tube normally offers
resistance (at the ileo-cæcal valve, sigmoid flexure, etc.), may lead
to ulceration in the same way. Schönlein has called attention to the
paralytic condition of the intestinal muscularis in age as a
predisposing cause of mechanical intestinal ulcer; and Virchow has
noticed the same condition among the insane, whose intense
preoccupation leads to neglect of evacuation of the bowels. Certain
intestinal parasites, more especially ascarides, are admitted as
occasional causes of ulceration, and more superficial solutions of
continuity in the rectum have been noticed as the result of too
frequent or too careless use of enemata.
{824} Curling was the first to call attention to the fact that
extensive burns of the skin are sometimes followed by ulceration of the
intestines. The ulcerative process is almost exclusively confined to
the duodenum. Various attempts have been made to explain the intestinal
ulcer consequent upon burning of the skin, but a satisfactory
explanation is lacking as yet. Leube suggests an inhibition in the
force of the circulation by reason of accumulation of waste products in
the blood, while Billroth believes the ulcer to be the result of an
embolic process. Whatever the cause, the frequency of its occurrence
makes it more than a mere coincidence. According to Meyer, it is
observed most frequently in women, and shows its first symptoms in
seven to fourteen days after the initial burn.
Aside from toxic and traumatic causes, ulcer of the intestine occurs as
the result of dysentery, typhoid fever, and tuberculosis--diseases
mentioned in the order of frequency in the production of intestinal
ulcer. The ulcers of dysentery in the large intestine, and of typhoid
fever in the small intestine, assume such prominence in these
affections--having even been erroneously considered at one time as the
cause of these maladies--that their study belongs to the history of
these diseases. The ulcer of tuberculosis is rather an accident in the
course of this affection, and is now recognized as the occasional
result of direct infection by the ingestion of tuberculous flesh, or,
far more frequently, of the deglutition of tuberculous sputum. As a
rule, the tuberculous ulcer shows itself late in the course of
pulmonary phthisis, and is the cause of the obstinate and colliquative
diarrhoea which speedily exhausts the patient. Yet cases are
occasionally met in which numerous or extensive ulcers occur in the
intestinal canal early in the history of phthisis, before any serious
damage has been inflicted upon the lungs. The tuberculous ulcer
affects, and for the most part is confined to, the same structures
which form the seat of disease in typhoid fever--viz. the solitary and
agminated glands of the ileum. When the bacilli tuberculosis are
conveyed to the intestine by means of the lymph- and blood-supply
through the mesenteric vessels, the resulting ulcer takes the shape of
the vascular arrangement; that is, the long axis of the ulcer is at
right angles to the course of the tube. Thus, if sufficiently
extensive, the ulcer may be circular or form a girdle or ring entirely
around the tube. With the tubercular ulcer or ulcers are usually found
tubercular nodules or plaques in the serous coat, which are visible to
the naked eye as opacities or milky deposits beneath the peritoneal
coat. The glands of the mesentery may be at the same time so much
increased in size as to form visible or palpable tumors in the abdomen.
The frequency with which tuberculosis affects the vermiform appendix
has already been noticed in detail in the etiology of perityphlitis.
The ulcer of the intestine which is the result of a catarrhal process,
so called, belongs to the history of chronic diarrhoea and dysentery.
The true intestinal ulcer, per se, which has its analogue in the
stomach as the gastric ulcer, ulcus rotundum, is due to the same cause
as in the stomach--viz. to arrest of circulation and erosion by the
gastric juice. It is a well-established fact in physiology that gastric
digestion is continued--is, indeed, mainly effected--in the small
intestine; hence it is not surprising to learn that an arrest of
circulation in the small intestine {825} is attended by the same
result. The fact that this so-called peptic ulcer is found almost
exclusively in the duodenum speaks most emphatically for this origin of
the disease. Arrest of the circulation in the intestinal wall may be
due to embolus, which, according to the observations of Nothnägel and
Parènski, is not infrequently found in the branches of the duodenal
artery; to infarction, the condition so commonly encountered in pyæmia
and septicæmia; or to thrombotic occlusion, as seen in amyloid
degeneration--a disease process which selects by preference the vessels
of the alimentary canal, along with those of the kidney and spleen.
The duodenal resembles the gastric ulcer in form as well as origin. It
has the same appearance, in its recent stage at least, of having been
cut out with a punch, shows no inflammation, induration, or thickening
about its borders, and presents the same funnel-shape with terraced
walls, its apex below eccentrically situated, as a rule corresponding
to the situation of the artery. It is most frequently found in the
upper horizontal portion of the duodenum, but is occasionally, though
rarely, seen in the descending portion. In the further course of the
duodenum the gastric juice becomes gradually neutralized, so that
ulcers situated below the orifice of the gall-ducts are very great
exceptions. In Krauss' collection of 47 cases but 2 were found in the
lower sections of the duodenum. The intestinal like the gastric ulcer
is usually found single or alone, but occasionally two, three, or even
four ulcers are encountered. According to the tables of Morot, a single
ulcer is found in 81.8 per cent. of cases, two in 9.2 per cent., and
three and four in 4.5 per cent. each.
Duodenal like gastric ulcers are attended with the liability to
hemorrhage and perforation in equal if not greater degree. There is
also the same tendency to implication of contiguous structures. Stich
records a case of perforation of the aorta; Eichenhorst mentions the
formation of abnormal communication with the gall-bladder; and
Frerichs, a thrombosis of the vena porta in consequence of duodenal
ulcer. Lastly, the process of cicatrization may be followed by the same
disasters as occur in pyloric ulcers in consequence of contraction and
constriction. Thus, the orifices of the pancreatic or choledochus ducts
may be narrowed or completely closed, or the whole lumen of the
duodenum obliterated, with consecutive dilatation of the stomach and
oesophagus, as in the case narrated by Biermer. A very nice question in
differential diagnosis as between pyloric carcinoma and pyloric or
duodenal ulcer is sometimes raised in this way. In the vast majority of
cases it is safe, even in the absence of a palpable tumor and without
regard to the age of the patient, to decide this question in favor of
carcinoma. Cases of complete occlusion constitute the rule in
carcinoma, and the very great exception in ulcer.
It remains to be said that duodenal is much more rare than gastric
ulcer, in the ratio of 1 to 30, and that, unlike gastric ulcer, it
chiefly affects males. According to the statistics of Krauss, already
cited, the ratio of males to females is 9 to 1, and according to Trier
the ratio is 5 to 1. It occurs in greatest frequency between the ages
of thirty to forty, diminishing in frequency with advancing age.
SYMPTOMATOLOGY.--Ulcer of the intestines announces itself by symptoms
which are, as a rule, much more vague and indefinite than the same
process in the stomach. In a certain percentage of cases the symptoms
{826} may be entirely latent, and the cause of a sudden death be
revealed only on the post-mortem table. In less severe cases the entire
symptomatology of intestinal ulcer is grouped under the term dyspepsia,
no characteristic phenomena being manifest throughout the course of the
disease.
On the other hand, a very small ulcer may give rise to the most
dangerous symptoms--hemorrhage and perforative peritonitis, which may
be even fatal in the course of a few days or hours.
Among the symptoms that appear with prominence in the course of the
disease is pain. Although cases are abundantly on record marked by the
entire absence of pain, and although pain is by no means so universally
present as in gastric ulcer, it occurs in the great majority of cases
of ulcer of the intestine. The pain of intestinal ulcer distinguishes
itself from gastric ulcer by being more independent of the character of
the food or the time of taking it. For the most part, it occurs in
attacks of colic, which are characterized at times by their extreme
severity, long duration, and obstinacy to every means of relief. These
attacks occur in paroxysms with complete or only incomplete remissions,
and are ascribed, as in gastric ulcer, to the erosive action of the
gastric juice upon exposed nerve-fibres, the intervals of relief
corresponding to the periods of exhaustion of the nerve-centres. At the
same time, in exceptional cases, a long-continued localized tenderness
to pressure may indicate the seat of the disease.
Palpation may elicit, besides tenderness, points or regions of
induration or intumescence. Such a condition is more especially
encountered in cases of tuberculous disease, the so-called scrofula of
the intestine or the tabes mesenterica of childhood. More localized
enlargements are occasionally to be felt in the vicinity of the
duodenal or other intestinal ulcer in consequence of circumscribed
peritonitis, with its resultant agglutinations and adhesions. In this
connection caution must be exercised not to confound masses of impacted
feces with tumefactions. The history of constipation or the
administration of a light laxative will generally suffice to remove
this source of error.