Part 141

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.

It is the cause and seat, rather than the existence, of the hemorrhage that mostly cause embarrassment in differential diagnosis. Hemorrhage from the lungs, nose, or stomach is usually readily excluded by the absence of any evidence of disease of these organs, and the presence of the other symptoms of any general disease attended with enterorrhagia makes a diagnosis in most cases easy enough. Alterations in the contents of the {834} bowel, the presence of foreign bodies, are recognized by the history of the case and by careful local examination, while a diagnosis of anomalies in the walls of the bowel is usually reached by exclusion. In no doubtful case should local inspection or digital examination of the anus and rectum be omitted.

TREATMENT.--As in all cases of hemorrhage, the first requisite is absolute rest. The patient should be at once put to bed and kept perfectly quiet. Many a case of hemorrhage in typhoid fever is produced by arising from bed to go to stool. The bed-pan is an absolute necessity in the management of a case of typhoid fever after the second week of the disease. Rest is the chief agent in prophylaxis as well as therapy.

The most effective styptic in enterorrhagia is cold. An ice-bladder should be laid upon or suspended immediately above the abdomen during the whole duration of the flow. The injection of ice-water into the bowel should be practised only in cases where the hemorrhage is believed to come from the colon. Otherwise, the peristalsis it awakens may only aggravate the danger. Should rest and cold fail to quickly check the hemorrhage, resort should be had at once to ergot. This remedy, in the form of ergotin, is most effective when introduced beneath the skin. In cases of less imminent danger the practitioner may be content to give the remedy by the mouth.

Small doses of the simple or camphorated tincture of opium frequently repeated speedily arrest contractions of the bowel, and at the same time feed the brain in threatening syncope. The astringents proper--tannic acid or its preparations, acetate of lead, alum, the perchloride of iron--are seldom necessary or advisable, but may be called for in obstinate or protracted cases.

To turpentine has been ascribed, from time immemorial, specific virtues in relief of hemorrhage of the bowels, and its administration is still a routine system with many older practitioners. It is most effective in large doses--one drachm, with milk or in emulsion, every hour or two until the hemorrhage ceases.

In relief of collapse, alcohol, ether, and musk are imperatively indicated, with the external application of heat; and in the treatment of the anæmia and hydræmia the preparations of iron, including, later, the mineral waters which contain it. In the worst cases of sudden alarming hemorrhage the physician should not fail to practise the transfusion of blood or solutions of salt or soda.

Milk is the best food and drink during the attack, and after it for some days or weeks. Chopped or scraped raw beef may substitute it later, while all farinaceous foods are to be strictly avoided for some time.

{835}

INTESTINAL OBSTRUCTION.

BY HUNTER MCGUIRE, M.D.

When a mechanical impediment to the passage of the contents of the bowel along the intestinal canal exists, the condition is known as intestinal obstruction. The causes of this occurrence are numerous, the symptoms urgent, the diagnosis difficult, the treatment uncertain, and the termination, unless relieved by nature or art, speedily fatal. There is no class of cases to which the practitioner is called more important, or which demands on his part greater skill and judgment.

It is customary to divide the causes of obstruction of the bowels into two great classes--acute and chronic.

In acute cases the attack is sudden, the symptoms violent, and, unless the cause is speedily removed, life ends in a few hours or at most in a few days. In chronic cases the causes act comparatively more slowly, the symptoms are chronic and less urgent, and danger of death less imminent. In this class the cause is not uncommonly spontaneously relieved, and the individual restored to perfect health without the aid of medicine or the surgeon's art. This result may happen in apparently the most desperate cases.

This classification of acute and chronic obstruction is necessary for a proper clinical study of the subject, but it should be remembered that in practice there will be found some cases which partake of many of the symptoms of both acute and chronic obstruction, making it difficult to determine to which division the cases properly belong. It will also be seen that some, at first, well-marked acute cases subside and become chronic in character, and that (old) chronic cases of obstruction sometimes suddenly change their nature and become acute. Again, some of the causes mentioned as giving rise to acute obstruction of the bowel in rare instances produce symptoms of chronic obstruction, and some of the causes referred to as giving rise to symptoms of chronic obstruction in rare instances provoke signs of acute obstruction. These cases are exceptional. As a rule, the following list embraces conditions which produce symptoms of acute obstruction:

1. Congenital malformations.

2. Impaction of foreign bodies, gall-stones, enteroliths, etc.

3. Twisting of the bowel--volvulus.

4. Internal strangulation by loops, bands, false membranes, diverticula, mesenteric pouches, slipping of a portion of bowel into natural or unnatural openings, diaphragmatic hernia, etc.

{836} 5. Invagination.

As a rule, the following causes produce symptoms of chronic intestinal obstruction:

1. Constipation and fecal accumulation.

2. Stricture of the bowel, sometimes cancerous.

3. Compression of the bowel from abdominal tumors.