A system of practical medicine. By American authors. Vol. 2

by Unknown

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 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.