appetite may amount to a complete aversion to all food or only to the
more fatty articles of diet. A curious exception to this rule is not
infrequently seen in the unappeasable hunger of children the victims of
tuberculous ulceration. The contrast offered in the extreme emaciation
of these patients has been made the subject of frequent comment.
With this loss or perversion of appetite and defective digestion of the
food, the general condition soon begins to fail. Though cases are
occasionally met in which a bien-être has been maintained for years, or
a condition of obesity has been retained, these cases form the
exception in the history of intestinal ulcer. More or less emaciation
gradually develops as a rule, and a reduction of the general strength
that is out of all proportion in its degree to the loss of flesh. At
the same time the mental condition of the patient suffers a degradation
to the level of the sufferer with chronic dyspepsia.
The disturbances of digestion which occur in intestinal ulcer present
many varieties in degree and kind. Some patients show none or but few
of the signs, while others run the gamut, so to speak, in the
semeiology of dyspepsia. Heartburn, eructations, pyrosis, borborygmi,
flatulence, gastralgias, pseudo-anginas, nausea, and vomiting, the
familiar {827} phenomena of gastric or intestinal catarrh, attend at
some time or other in the course of the disease most of the cases of
intestinal ulcer.
The condition of the discharges demands notice in detail, more
especially as abnormalities in the evacuations belong among the few of
the more constant symptoms of the disease.
Diarrhoea is the rule in intestinal ulcer. The discharges consist at
first of the undigested food and the digestive juices, which have been
hurried along the alimentary canal and prematurely evacuated on account
of the increase of peristalsis caused by the irritation in the upper
part of its tract. The arrest of the digestive process leads to early
decomposition of the ingested matters, and thus imparts to the
discharges an exceedingly offensive odor. While, in exceptional cases,
constipation may be present, or even obstipation of the bowels, the
discharges are usually so abundant as to constitute a diarrhoea, which
in some cases is so frequent or profuse as to become colliquative and
speedily exhaust the strength of the patient.
An ulceration situated in the colon or rectum would furnish the
discharges characteristic of dysentery, already described in detail,
while the same process in the ileum would show the evacuations
characteristic of typhoid fever or tuberculosis.
The most characteristic ingredient of the true duodenal ulcer is blood.
As stated in the article on HEMORRHAGE OF THE BOWELS, ulcer of the
intestine constitutes the most frequent source of this accident, which
is sometimes so grave as to destroy life in the course of a few days or
hours. The blood from an intestinal ulcer may be evacuated both by the
mouth and the anus, or may be retained in the alimentary canal and not
appear at all. Such cases constitute the condition known and described
under the heading of occult or concealed hemorrhage, which is
recognized by the rapid general collapse of the patient. When the blood
issues from a duodenal ulcer, it is intimately commingled with the
contents of the alimentary canal. The discharges in such cases are
usually black, tarry, and more or less fluid; whereas blood from the
colon or rectum still preserves its fresh red color and is discharged
separate from the feces or simply coats its exterior. Occasionally
cases are met where the blood coagulates in the interior of the
intestinal canal, to form a cast of its lumen or to accumulate in great
mass in the sigmoid flexure or rectum. In one case in the experience of
the author such an accumulation was the cause of a very severe
tenesmus, which was only relieved by the digital evacuation of large
masses of inspissated, coagulated blood.
The presence of pus would indicate lesion of the colon, as typically
shown in dysentery, as suppuration, at least with any visible products,
does not occur in ulcer of the duodenum.
DURATION.--Ulcer of the intestine has no definite duration. As in the
case of its prototype, gastric ulcer, it may speedily be covered with
cicatricial tissue and never appear again in the course of a long life.
But such a course is as unusual as in gastric ulcer. Frequent
recurrence constitutes the rule in intestinal ulcer, or a partial
recovery with frequent relapses, as in the course of ulcer of the
stomach. So ulcer of the intestine is not infrequently a lifetime
malady, with exacerbations and remissions dependent largely upon the
prudence or imprudence of the patient with regard to diet. It need
hardly be stated that ulcer of the intestine {828} may terminate
fatally even in the course of a few days from hemorrhage, circumscribed
and later diffuse peritonitis, or may drag out a slow length of years,
to finally destroy the patient with the general symptoms of inanition,
hydrops, and marasmus.
DIAGNOSIS.--From what has been already stated, it is seen that ulcer of
the intestine is often entirely overlooked or may be readily confounded
with other maladies of the digestive tract. Cases of traumatic or toxic
origin are generally readily recognized by the history of the patient,
and tuberculosis reveals itself by the youth of the individual, the
existence of the disease elsewhere, the gradual emaciation, the
premature senescence--in short, the general signs of the phthisical
habitus, the meteorism, and perhaps the presence of nodular
enlargements of the mesenteric glands.
The most characteristic symptom of the peptic ulcer is, as has been
stated, hemorrhage. But hemorrhage is present in only the minority of
cases, is, as a rule, occasional and transitory, and is at all times
difficult of differentiation as to its source. Blood from a gastric
ulcer may also be voided per rectum as well as per os, and the blood
from a duodenal ulcer after regurgitation may be wholly discharged by
vomiting. The absence of vomiting and the presence--more especially the
persistence--of tarry evacuations from the bowels would speak for ulcer
of the intestine. Dilatation of the duodenum, a condition of ectasia,
closure of the bile-duct with consecutive jaundice, or the presence of
fatty stools from occlusion of the pancreatic duct (a sign not now
regarded of the same value as in the days of Bright), would also
declare in favor of ulcer in the duodenum.
As between intestinal ulcer and catarrh or intestinal ulcer and
carcinoma, precisely the same rules would hold as in the case of the
stomach. A simple enteralgia would be recognized by its more frequent
occurrence among females or individuals of neurotic temperament; by its
connection with faults of diet, malaria, or exposure to cold; by the
absence of hemorrhage, diarrhoea, or peritonitis.
PROGNOSIS.--Too much caution cannot be exercised in the prognosis of
ulcer of the intestine; for even in the cases which run a perfectly
mild course the gravest, even fatal, accidents are liable to occur. The
danger of perforation in cases of typhoid fever from a single or from
one of the few ulcers that may be present imparts one of the chief
elements of gravity to this disease; and the same catastrophe may occur
at any time in dysentery or tuberculosis. The duodenal ulcer may
likewise have a sudden gravity imparted to a mild case by a copious
hemorrhage or a peritonitis, and, even though the patient escape all
possible complications, to recover with the surface of the ulcer healed
so that the loss of substance is filled in with firm cicatricial
tissue, the danger of contraction or stenosis still remains. The ulcers
of dysentery in the colon and of syphilis in the rectum are especially
liable to be followed by deformities of this kind, while the
tuberculous ulcer in the ileum not infrequently results in a more or
less complete stenosis. The ulcer of typhoid fever in its cicatrization
almost never reduces the size of the intestinal canal.
TREATMENT.--The most valuable therapeutic means of relieving the pain
and obviating the dangers of ulcer of the intestine consist in the
{829} regulation of the diet. The food should be light, easily
digestible, and during the acute stage of the disease as nearly fluid
in its consistency as may be. Milk would be the staple article of diet
in all cases were it not for the fact that in some cases constipation
attends its too exclusive use. The various soups, without solids,
broths, preparations of starch (sago, arrowroot, tapioca, etc.), may
sufficiently nourish the patient until the healing process shall have
commenced. Raw beef, chopped up and made into an emulsion, is perhaps
the most nutritious and least injurious of any kind of food. Bread,
potatoes and other vegetables should be ruled out altogether, because
of their liability to produce masses of feces whose inspissation may do
mechanical damage to ulcers in process of cicatrization.
Where there is failure in the general strength early resort should be
had to alcohol, which may be administered in the form of red wine (in
preference to white, because of the tannin it contains), wine-whey, or,
in more serious prostration, of sherry wine, milk punch, egg-nog made
with good whiskey or brandy.
In the worst cases, where all food irritates, feeding by the mouth may
be abandoned altogether for a time, and the strength of the patient
sustained by nutritive enemata of beef or pancreatic emulsion.
The diarrhoea should be controlled rather than entirely checked, for
fear of the greater evil of constipation. A little bismuth with
bicarbonate of sodium or oxide of zinc may suffice for the milder
cases, while in the more aggravated cases resort must be had sooner or
later to opium.
Constipation is best relieved by careful injections of warm water or by
the administration of the lighter laxatives--mineral waters, Seidlitz
powders, citrate of magnesia, castor oil, etc.
Vomiting is combated by ice, soda-water, champagne, cherry-laurel
water, and in graver cases morphia hypodermically.
Pain may be relieved by applications of hot water, cataplasms,
injections of hot water, and, when necessary, by morphia with or
without belladonna.
Hemorrhage is checked by ice internally and externally, turpentine,
ergot or preferably ergotin by hypodermic injection, and opium.
Peritonitis, more especially perforative peritonitis, calls
imperatively for the liberal use of opium.
Patients the victims of intestinal ulcer must maintain a guarded diet
for months, often for years, after all signs of the disease have
disappeared as the best prophylaxis against recurrence. Constant
vigilance is also required to avoid constipation, and the greatest
temperance exercised with regard to the use of alcohol. The author has
at the present time a patient under treatment who presents all the
symptoms of duodenal ulcer, including hemorrhage, with every indulgence
in strong drink, and in whom all symptoms disappear under entire
abstention. Sometimes a course of mineral waters, a sea-voyage, or
other change of life or scene constitutes the best means of avoiding
frequent relapse.
It need hardly be said that an ulcer in the rectum, which is readily
recognized by its attending tenesmus, calls for local treatment; and it
is equally plain that tuberculosis or syphilis requires appropriate
internal means of relief.
{830}
HEMORRHAGE OF THE BOWELS.
BY JAMES T. WHITTAKER, M.D.
GENERAL REMARKS.--Hemorrhage of the bowels occurs in both sexes, though
more frequently in the male, and at all ages, though more frequently at
the middle period of life. In the infant a form of it is sometimes
considered as a distinct affection under the head of melæna neonatorum,
and in age it sometimes shows itself as a distinct sign of a disease
characteristic of age--namely, cancer. According to the tables of
Bamberger, it is caused in the order of frequency by dysentery, typhus
fever, cancer (of the colon), mechanical injury, poisons and foreign
bodies, ulceration (tubercular, follicular), the round ulcer of the
duodenum, and aneurism; last and least frequent is the so-called
vicarious hemorrhage.
ETIOLOGY.--Hemorrhage from the intestinal canal arises from (1)
anomalies in the contents of the bowel; (2) disease of the wall of the
bowel; and (3) from general diseases.
(1) The inspissation of the natural contents of the bowel during
long-standing or habitual constipation may convert the feces into dense
masses which irritate and scratch the mucous membrane, and thus induce
hemorrhage directly by simple solution of continuity, or indirectly as
the result of extreme hyperæmia. Such hemorrhage is nearly always
slight, streaking or coating the surface of the scybalous mass or being
extruded from the anus as a small deposit of blood during the last act
of defecation; in which latter case it is found mostly associated with
hemorrhoids or fissure of the anus--conditions which require separate
description. Independent of these conditions, the hemorrhage nearly
always has its origin in the lowest regions of the large intestine,
where condensation of the feces is naturally greatest.
Foreign bodies in the intestinal canal descended from the stomach may
also be the cause of hemorrhage in the same way. Thus, stones of
fruits, bones of fish, fragments of oyster-shell, or other substances
in no way connected with aliments (false teeth, buttons, pins and
needles, etc.), may be swallowed accidentally or purposely (as by
children or the insane) to produce intestinal hemorrhage. Drastic
cathartics (podophyllin, gamboge, etc.) and poisons (arsenic, mineral
acids) occasionally act in the same way. Thus, Tardieu reports[1] the
case of a servant to whom was administered by a homoeopath veratrin
with coffee, with fatal effect in six days. At the autopsy, made by
Amussat and Reymond, the stomach and small {831} intestine were found
filled with a dark-brown or black bloody fluid, but there was no trace
of perforation, ulceration, or organic disease.
[Footnote 1: _Annales d'Hygiène_, July, 1854.]
Under this head mention should be made also of certain parasites whose
habitat is the intestinal canal, the walls of which they perforate. Two
varieties, the Anchylostoma duodenale and the Distoma hepaticum, are
frequent causes of hemorrhage, the former from the duodenum and
jejunum, the latter from the rectum, in hot climates, more especially
in India and Egypt.
(2) Anomalies in the intestinal walls produce hemorrhage as the result
of intense hyperæmia (per diapedesin) or of actual loss of substance
(per rhexin). Copious, even fatal, hemorrhage has thus ensued from
dysenteric and typhoid processes (and even without discoverable cause)
where no ulceration or loss of substance could be discovered on
autopsy; and this accident is so frequent as the result of ulceration
in the diseases mentioned as to constitute a characteristic sign or
complication. It must be said, however, that cases of alarming or fatal
hemorrhage without apparent cause during life or lesion after death
were more frequently reported in the literature of the times preceding
our more accurate knowledge of pathology and pathogeny. Few clinicians
or pathologists would now be content with reports made without full
knowledge of the history of the case or microscopic examination of the
intestinal walls. Thus, the report to the Société Médicale d'Emulation,
April 2, 1834, by Dubois of a young man who quickly died of intestinal
hemorrhage five days after a severe headache, and on the same occasion
by Guillemot of several similar cases, would awaken the suspicion of
masked typhoid fever; and the case of an old man aged seventy-four who
died of intestinal hemorrhage after four days' diarrhoea, reported by
Husson,[2] would call for a close examination of the vessels in the
intestinal walls. In fact, Bricheteau, who reported a case from the
Hôpital Neckar, was able on autopsy to discover a rupture in a small
artery of the intestines.
[Footnote 2: _Proceedings of the Anatomical Society at Paris_, 1835.]
Embolic processes leading to the formation of ulceration (by
predilection in the duodenum) are often attended with intestinal
hemorrhage, which would be more constantly present were it not for the
fact that, as in the stomach, the speedy establishment of collateral
circulation prevents the consequences of complete infarction.
Besides dysentery and typhoid fever, tuberculosis and syphilis are
occasional causes of ulceration and necrosis of the intestinal walls
which may be attended with hemorrhage. Cancer of the intestine most
frequently affects the rectum, but wherever situated may show
hemorrhage as one of its signs.
The local hyperplasia of the mucous tissue which constitutes a
polypus--and which in children, in whom it most frequently occurs, is
mostly situated in the rectum--is suspected to exist or is recognized
by the frequent discharge of blood from the bowels. A far more grave
affection of the intestinal walls, likewise most frequent in childhood,
is the peculiar dislocation known as intussusception or invagination.
This condition is so commonly attended with distressing evacuations of
blood and mucus as to simulate dysentery. The strangulation of the
intussuscepted mesentery with its vessels easily accounts for the
hemorrhage in such cases.
A more extensive compression is exercised at times by tumors in the
{832} abdominal cavity, as by pregnancy, ovarian growths, etc.,
occlusions in the course of the portal system (cirrhosis hepatis),
interference with the general circulation, as in diseases of the heart
or lungs, with intestinal hemorrhage as a consequence.
Diseases of the blood-vessels themselves, as amyloid degeneration,
aneurism, should not be omitted from the list of factors possibly
productive of this result.
(3) The general diseases attended with hemorrhage from the bowel are
characterized for the most part by more or less general disintegration
or dissolution of the blood, with the manifestation of hemorrhage in
various parts of the body--kidneys, uterus, subcutaneous tissue, etc.;
the enterorrhagia being an accidental localization, so to speak, of the
effusion. The most prolific causes of this disorganization are the
micro-organisms which "touch the life of the blood corruptibly;" and
hence the various acute infectious diseases may show in the severer
forms hemorrhage from the bowels. Under this head may be ranged
variola, which boasts even of a hemorrhagic form; typhus, yellow, and
malarial fevers; the forms of nephritis marked by uræmia, cholera,
icterus gravis, erysipelas, etc. Disintegration of the blood or partial
dissolution of its corpuscular elements occurs also in those obscure
affections which constitute the group, or are included in the
description, of the hemorrhagic diatheses, as hæmophilia, leuchæmia,
pernicious anæmia, scurvy; of any of which enterorrhagia may be a
distinct or dangerous sign.
Melæna neonatorum is the distinct name given to a hemorrhage from the
bowels which occurs a few hours or days after birth, and which is often
so profuse as to cause death at once or in a short time. In most cases
no anatomical lesions can be discovered after death, save an intense
hyperæmia of the intestinal mucosa, so that the etiology of this
affection is involved in obscurity. The various causes assigned in its
production--ulceration of the stomach or duodenum (Bohn), embolism
(Landau), fatty degeneration (Steiner), premature ligature of the
umbilical cord (Kiwisch)--answer only for individual cases. Betz
reported a case in a family subject to hæmophilia, and Trousseau once
saw twins thus affected; but that heredity cannot account for all cases
is shown by the fact that it occurs mostly in healthy children from
healthy parentage. Klebs is inclined to attribute the affection to the
action of micro-organisms, introduced perhaps as the result of
puerperal infection, but this cause can be assumed in only a small
minority of cases; at least, but a small percentage of cases coincide
with puerperal disease on the part of the mother.
The affection is fortunately rare. Eichhorst states that Hecker
observed it but once in 500 births, and Gemich but once in 1000 births.
According to Rilliet, the hemorrhage is oftener (8/14) intestinal,
rarer (4/14) gastric, and rarest (2/14) both. It is almost always
abundant and quickly repeated, the blood being mostly pure, in clots or
masses and fluid, though it is sometimes commingled with meconium. It
usually ceases within twenty-four hours, though it may continue for
three, five, or more days. Of 23 cases reported by this author, 12
recovered and 11 died.
MORBID ANATOMY.--Hemorrhage from the bowels, being only a symptom of
very many different conditions, is marked by lesions characteristic of
the condition in an individual case. These lesions are more
appropriately described in connection with the various diseases. Not
{833} infrequently in these cases the intestine is distinguished by the
absence of any lesion at all; but, from whatever cause, hemorrhage from
the bowels, like hemorrhage from any other source, shows a more or less
profound anæmia of all the internal organs, and in more chronic and
protracted cases leads to fatty degeneration, more especially of the
heart.
SYMPTOMATOLOGY.--Hemorrhage from the bowels is usually readily
recognized by the discharge of blood, either pure or mixed with the
natural contents of the alimentary canal. The actual seat of the
hemorrhage may, however, only rarely be recognized by the rectal
speculum. The colicky pains, borborygmi, or sensations of fluids in the
abdomen which are occasionally experienced may not be relied upon in
fixing the seat of the effusion. Should the hemorrhage occur in
quantity, or, more especially, should the seat of the effusion be low
in the intestinal canal, the blood which escapes is more or less pure.
When the hemorrhage is higher, or when the stay of the blood in the
bowel is longer, it becomes more or less incorporated with the contents
of the bowels or altered by the intestinal juices to present a
discharge of mushy or semi-fluid consistence, of dark-brown or black
color. So-called tarry stools are thus largely composed of blood.
But serious, even fatal, hemorrhage sometimes occurs without the escape
of any blood at all. Such are the so-called cases of concealed, occult,
or internal hemorrhage, in which the nature of the malady is only
suspected or recognized by the general symptoms attending the profuse
loss of blood. Should the hemorrhage be gradual, anæmia slowly
supervenes, with hydræmia and subcutaneous dropsy. Traube reports a
fatal case of oedema of the glottis from such a cause. Sudden
hemorrhage announces itself by pallor and prostration, dyspnoea,
vertigo, and syncope. Amaurosis, tinnitus aurium, formication, emesis,
and, if the disease be high up in the intestinal canal, hæmatemesis,
are the common attendants of serious hemorrhage. In the worst cases of
sudden effusion the patient may present the appearance of complete
collapse, and the intestinal canal be found on autopsy distended with
blood throughout a great part of its course, while no blood whatever
has escaped from the rectum. In such cases, or with more gradual loss
of blood, the patient experiences a sense of increasing weakness, the
skin becomes cold and bedewed with a clammy sweat, the pulse grows
feebler, the temperature falls, and death from exhaustion more or less
speedily ensues.
DIAGNOSIS.--The presence of blood in any quantity in the stools is
readily recognized by its coarser characteristics. Ridiculous errors
have been made by mistaking the coloration produced by bismuth, iron,
logwood, etc. administered internally, or by coloring matters
introduced into the discharges for purposes of deception. The
microscope, Zeichmann's test for blood-crystals, and in extremely
doubtful or medico-legal cases the spectroscope, furnish easy means of
detecting blood in whatever quantity or character.