The condition having occurred admits of but one remedy—namely, operation. One of the latest collections of statistics includes 63 operations for typhoid perforation, with 11 recoveries, although probably today the percentage is somewhat better than in 1903. Operations to be effective should be immediate. Patients are usually too profoundly collapsed to justify general anesthesia, unless perhaps this may be secured with ethyl chloride or somnoform. Many of them have been operated under local anesthesia. This has its disadvantages, however, in that it is so difficult to make free opening and exploration or free toilet. Opening having been effected, the loops of intestine must be successively examined until the site of the perforation is discovered. Here sutures must be applied, if possible. Should the condition of the bowel render it absolutely unreliable, i. e., should it be too extensively gangrenous to retain sutures, it should be brought out and an artificial anus made, at least for temporary purposes. In addition to these measures the most careful toilet of the peritoneum is needed, perhaps including extensive irrigation, unless it can be shown that the area contaminated by extravasation is localized and shut off.
Perforation of tuberculous, dysenteric, cancerous, or other ulcers will cause symptoms very much like those of typhoidal perforation, and the case will differ essentially only in this respect, that in most of the latter the general condition of the patient will not be so extreme, and the danger of administering an anesthetic or of operating not so great. Otherwise the indication, the necessity, and the method do not differ.
Tuberculous Ulcers.
—Tuberculous lesions of the small intestines produce less destructive features than when situated in the colon. Tuberculous infection of the intestinal tract occurs more often through the swallowing of infected sputum, and, consequently, is a frequent condition among consumptives. Such lesions in the small intestines will lead to infection of the mesenteric nodes which, in time, may become serious or even fatal, or it may lead to tuberculous peritonitis with its finally disastrous consequences. As a rule, however, tuberculous ulcers are not so likely to perforate, this being in large measure due to the frequency with which they contract adhesions or affix diseased surfaces to others, thus rather guarding against such an accident.
Symptoms.
—Tuberculosis may also appear throughout the intestinal tract in miliary form, or we may find tuberculous gummas, either in the folds of the peritoneum or subperitoneally in the wall of the bowel. Any of these lesions may lead to any of the others, and by the time the case has been diagnosticated or has come to operation or autopsy it is sometimes difficult to say what was the primary lesion. Diagnosis is made partly with the thermometer and partly by inspection and palpation, where one may be able to discover mesenteric enlargements or the presence of fluid, as it usually collects in tuberculous peritonitis; and perhaps partly by the general appearance of the stools, in which a careful search may possibly, although by no means with certainty, reveal the tubercle bacilli.
Treatment.
—The treatment of such tuberculous lesions is largely constitutional. When the case assumes the aspect of tuberculous peritonitis much more can be accomplished by abdominal section and irrigation, at which time it may be possible to remove some localized focus without thereby doing more harm than good. The usual constitutional measures, including oxygen, are indicated; but there maybe difficulty in forcing hypernutrition because of the actual state of ulceration. In this case foods which are cared for by the stomach should be given in preference. Such intestinal antiseptics as creosote or other remedies of its class may also be pushed to the point of toleration.
The other granulomas produced by either syphilis or actinomycosis may give rise to ulceration and its consequences and sequels, in a way resembling those of tuberculosis. While the lesions they produce may give rise to uncertain symptoms, a diagnosis can hardly be made without accurate history and without the co-existence of other lesions in more accessible parts of the body, by whose character they may be determined. Primary actinomycosis of the intestinal tract is more common than is generally realized. As it develops it tends to spread to adjoining viscera and form tumors which later may break down. The debris thus resulting will be indicative, especially when the characteristic calcareous particles are felt in it, or the characteristic ray fungus discovered with the microscope. (See [Actinomycosis].)