Part 140

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 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.

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, 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.

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.