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Intestinal tuberculosis
514
TUBERCLE·
miliary involvement is not included in the series studied. Twelve of the 16 cases were of the ulcerative variety. The appendix in these cases often appears normal or slightly congested, but the mucosa shows ulcerative lesions or may be almost entirely destroyed. Microscopically the mucosa. and submucosa show extensive involvement and often extensive caseation uecrosis. The hyperplastic type, of which there were four in this series, is most readily diagnosed at or even before operation. '.fhe muscularis is primarily affected, the mucosa being usually intact, the submucosa possibly showing a few tubercles. 'l'he prognosis of the hyperplastic type seems to be considerably better than that of the ulcerative type,but in neither is the prognosis good. With regard to the route of infection, most authorities are against the probability of primary iufection of the appendix by way of the bloodstream. Most cases show involvement of the crocum, the most probable routes of infection, therefore, being by dire·ct extension and by infected contents. The three cases of acute appendicitis, of which details are given in this paper, were diagnosed before operation. The pre·operative diagnosis would seem to dopend on tho presence of at least two or three of tho following factors: (1) Longer duration of symptoms than in the average caso of acute appendicitis, without fulminating courseperforation, peritonitis, &c.; (2) poor nutrition and loss of weight; (iI) known presence of pulmonary tuberculosis; (4) diarrhroa; (5) rise of temperature not above 100·5° F.; (6) absence of vomiting; (7) tumour in the right lower quadrant. None of these alone is diagnostic, but the presence of several should suggest the true diagnosis. Two of the five cases where primary drainage was employed developed sinuses; as also did one case out of 11 which were not drained at operation. E. GllANET Intestinal Tuberculosis. Amer. JOllrn. Dig. Dis. aml. Nutrition, 1935, 11,209.
The incidence of intestinal tubercu· losis and its relation to pulmonary tuberculosis has been the subject of
[August, 1936
many papers and inquiries, and the conclusions arrived at have reached a larger measurement of agreemellt tban is often the case with problems of this kind. A now clinical, radiological and clinical study of intestinal tuberculosis in 2,086 patients suffering from pulmonary tuberculosis has recently been carried out by the author. Of these 2,086 patients (consecutive save for the exclusion of far-advanced toxic or terminal cases), 38 per cent. were found to have definite radiographic evidence of tuberculous enteritis. The diagnosis was mado on the presence of one or more of the following signs : I.-Crocum aud Ascending Colon: (a) Stierlin phenomenon; (b) spastic filling defect; (c.) filling defect with palpable tumour (granuloma); (d) persistent irregularity of crocum aftor re-examina-. tion-non-filling, narrowing, or irregular spasm of croco-colic valve; (e) persistent mottling after re-examination. n.-I1eum: (a) Segmentation and dilatation of ileal loops; (b) matted adherent ileal loops. Post-mortem examination showed the accuracy of these radiological criteria, since the finding was confirmed in 88 per cent. of the cases coming to autopsy. The writer points out how far we havo travelled since the day when intestinal tuberculosis was diagnosed by tho onset of intractable diarrhroa, there being now general agreement that symptoms often occur late in tuberculous enteritis. J n the author's serie!:! of cases a number of patients whOEe X-ray showed extensive intestinal ulceration had a complete absenco of gastrointestinal symptoms, while, conversely, of 999 tuberculous pationts in whom radiography showed a relatively norlDal gastro-intestinal tract, 175 (18 per cent.) complained of pain, constipation, dyspepsia, diarrhroa, or vomiting and constipation alternating with diarrhroa. These findings strongly emphasise the futility of depending on symptoms for the early diagnosis of intestinal tuberculosis. 1'he study, as might be expected, confirmed the direct relationship between positive sputum and tuberculous enteritis. 'l'he fact that patients with positive sputum are constantly
August, 1936] .
INTESTINAL TUBERCULOSIS
roinfecting their. intestinal mucous membrane is an obvious additional reason for the early institution, whero possible. of adificial pneumothorax· or thoracoplasty, in tho hope of ridding tho sputum of tubercle bacilli. Ulcerative pl'Octitis appears to be fk late sign in the disease, and· consequently sigmoidoscopy is of little value as an early diagnostic measure. The distribution of the lesions was {ound to be, in descending order of frequency: ileo-crocal; crocal only; the wholo length of large and small intestine; ileum, erocum and ascending colon; ileum only; croCUlll and ascending colon; jejunum, ileum and crocum ; jejunum alone or with ileum; jejunum and crocum; ascending, transverse and descending colon; and sigmoid only. The last three of those were met with in one caso each, as compareu with. ileo-crocal at the other end of the scale, with 53 cases. Tho writer in a final section of his paper discusses the therapy of intestinal tuberculosis. Tho measures to be taken depend primarily on inactivation of the source of infection in the lungs. For the intestinal lesions themselves the measures are general and specific, the latter being directed mainly towards Granet's affording peristaltic rest. standard dietary ensures a smooth low residue lind high caloric values, with additional tomato juice and cod-liver oil, giving an excess of vitamins C and D. In any case, treatmont of the primary focus of infection is essential, failing which, improvement in the intestinal lesions is in the highest degree improbable. A~IEUILLE.
P., and DUPEnnAT.
La
Perforation de l'enterite uleereuse des tuberculeux. B. ct Mlm. Soc. Mhl. des
Hop. de Paris. 1()30, 52, 7,10.
The frequency of ulcerating enteritis is perhaps not recognised because in at least half the cases in which it is present anatomically it gh'ss riso to no functional disturbances to attract attention. Autopsy statistics, howover, show that it is present in at least two out of three tuberculous cadavers. It is commonly taught, moreover, that pflrforatioll occurs very seldom, in strong contrast
515
with the frequency of perforation in typhoid ulceration, and that "hen it does occur it is in a fold of the peritoneum, not into the general peritoneal cavity. The study of 12 cases of perforation in four years in tho tuberculosis section of tho Cochin Hospital, and a study of French and foreign statistics, have convinced the writers that both these commonly beld ideas are mistaken; that perforation is far from being a rarity in ulcerating enteritis in tuberculous patients; that it nearly always occurs into the general peritoneal cavity; that nevertheless its SY1Dptomatology may be lacking-which explains why it is seldom recognised during life -and that perforation into the peritoneal cavity may be included among tho immediate causes of death in pulmonary tuherculosis. Ulcerative enteritis, always secondary to pulmonary tuberculosis, may be suspected in cases of abdominal pain and intractable diarrhroa, radiology sometimes confirming the diagnosis. The point to which the writers wish to draw attention, however, is that in 3 per cont. of pulmonary tuberculosis cases an intestinal perforation may be seen on careful post-mortem examination. The perforation may be singlo or multiple, and though most frequently seen at the end of the ileum, it may occur at any part of the small intestine and even in the colon. A paradoxical fact in this connection is that \vhile there must always be in such cases a mom or less abundant purulent or fro cal fluid in the peritoneal cavity, yet the peritoneal reaction to the perforation is minimal, the organism of the patient doubtless being unable to put up any defence. The floor of the ulceration is astonishingly thin, so much so that it is a matter· for surprise that perforation does not occur more often. Clinically, perforation mny be evidenced in two different ways: suddenly, with the signs of an acute peritonitis, or it may be of tho latent, asthenic type in which tho general condition becomes rapidly worse, dyspnroa and cyanosis increase, the pulse becomes uncountable without any abdominal signs, death taking place in a few hours, or more rarely in two or three days. Nine of the 12 ea"es in the writers'
TUBERCLE·
miliary involvement is not included in the series studied. Twelve of the 16 cases were of the ulcerative variety. The appendix in these cases often appears normal or slightly congested, but the mucosa shows ulcerative lesions or may be almost entirely destroyed. Microscopically the mucosa. and submucosa show extensive involvement and often extensive caseation uecrosis. The hyperplastic type, of which there were four in this series, is most readily diagnosed at or even before operation. '.fhe muscularis is primarily affected, the mucosa being usually intact, the submucosa possibly showing a few tubercles. 'l'he prognosis of the hyperplastic type seems to be considerably better than that of the ulcerative type,but in neither is the prognosis good. With regard to the route of infection, most authorities are against the probability of primary iufection of the appendix by way of the bloodstream. Most cases show involvement of the crocum, the most probable routes of infection, therefore, being by dire·ct extension and by infected contents. The three cases of acute appendicitis, of which details are given in this paper, were diagnosed before operation. The pre·operative diagnosis would seem to dopend on tho presence of at least two or three of tho following factors: (1) Longer duration of symptoms than in the average caso of acute appendicitis, without fulminating courseperforation, peritonitis, &c.; (2) poor nutrition and loss of weight; (iI) known presence of pulmonary tuberculosis; (4) diarrhroa; (5) rise of temperature not above 100·5° F.; (6) absence of vomiting; (7) tumour in the right lower quadrant. None of these alone is diagnostic, but the presence of several should suggest the true diagnosis. Two of the five cases where primary drainage was employed developed sinuses; as also did one case out of 11 which were not drained at operation. E. GllANET Intestinal Tuberculosis. Amer. JOllrn. Dig. Dis. aml. Nutrition, 1935, 11,209.
The incidence of intestinal tubercu· losis and its relation to pulmonary tuberculosis has been the subject of
[August, 1936
many papers and inquiries, and the conclusions arrived at have reached a larger measurement of agreemellt tban is often the case with problems of this kind. A now clinical, radiological and clinical study of intestinal tuberculosis in 2,086 patients suffering from pulmonary tuberculosis has recently been carried out by the author. Of these 2,086 patients (consecutive save for the exclusion of far-advanced toxic or terminal cases), 38 per cent. were found to have definite radiographic evidence of tuberculous enteritis. The diagnosis was mado on the presence of one or more of the following signs : I.-Crocum aud Ascending Colon: (a) Stierlin phenomenon; (b) spastic filling defect; (c.) filling defect with palpable tumour (granuloma); (d) persistent irregularity of crocum aftor re-examina-. tion-non-filling, narrowing, or irregular spasm of croco-colic valve; (e) persistent mottling after re-examination. n.-I1eum: (a) Segmentation and dilatation of ileal loops; (b) matted adherent ileal loops. Post-mortem examination showed the accuracy of these radiological criteria, since the finding was confirmed in 88 per cent. of the cases coming to autopsy. The writer points out how far we havo travelled since the day when intestinal tuberculosis was diagnosed by tho onset of intractable diarrhroa, there being now general agreement that symptoms often occur late in tuberculous enteritis. J n the author's serie!:! of cases a number of patients whOEe X-ray showed extensive intestinal ulceration had a complete absenco of gastrointestinal symptoms, while, conversely, of 999 tuberculous pationts in whom radiography showed a relatively norlDal gastro-intestinal tract, 175 (18 per cent.) complained of pain, constipation, dyspepsia, diarrhroa, or vomiting and constipation alternating with diarrhroa. These findings strongly emphasise the futility of depending on symptoms for the early diagnosis of intestinal tuberculosis. 1'he study, as might be expected, confirmed the direct relationship between positive sputum and tuberculous enteritis. 'l'he fact that patients with positive sputum are constantly
August, 1936] .
INTESTINAL TUBERCULOSIS
roinfecting their. intestinal mucous membrane is an obvious additional reason for the early institution, whero possible. of adificial pneumothorax· or thoracoplasty, in tho hope of ridding tho sputum of tubercle bacilli. Ulcerative pl'Octitis appears to be fk late sign in the disease, and· consequently sigmoidoscopy is of little value as an early diagnostic measure. The distribution of the lesions was {ound to be, in descending order of frequency: ileo-crocal; crocal only; the wholo length of large and small intestine; ileum, erocum and ascending colon; ileum only; croCUlll and ascending colon; jejunum, ileum and crocum ; jejunum alone or with ileum; jejunum and crocum; ascending, transverse and descending colon; and sigmoid only. The last three of those were met with in one caso each, as compareu with. ileo-crocal at the other end of the scale, with 53 cases. Tho writer in a final section of his paper discusses the therapy of intestinal tuberculosis. Tho measures to be taken depend primarily on inactivation of the source of infection in the lungs. For the intestinal lesions themselves the measures are general and specific, the latter being directed mainly towards Granet's affording peristaltic rest. standard dietary ensures a smooth low residue lind high caloric values, with additional tomato juice and cod-liver oil, giving an excess of vitamins C and D. In any case, treatmont of the primary focus of infection is essential, failing which, improvement in the intestinal lesions is in the highest degree improbable. A~IEUILLE.
P., and DUPEnnAT.
La
Perforation de l'enterite uleereuse des tuberculeux. B. ct Mlm. Soc. Mhl. des
Hop. de Paris. 1()30, 52, 7,10.
The frequency of ulcerating enteritis is perhaps not recognised because in at least half the cases in which it is present anatomically it gh'ss riso to no functional disturbances to attract attention. Autopsy statistics, howover, show that it is present in at least two out of three tuberculous cadavers. It is commonly taught, moreover, that pflrforatioll occurs very seldom, in strong contrast
515
with the frequency of perforation in typhoid ulceration, and that "hen it does occur it is in a fold of the peritoneum, not into the general peritoneal cavity. The study of 12 cases of perforation in four years in tho tuberculosis section of tho Cochin Hospital, and a study of French and foreign statistics, have convinced the writers that both these commonly beld ideas are mistaken; that perforation is far from being a rarity in ulcerating enteritis in tuberculous patients; that it nearly always occurs into the general peritoneal cavity; that nevertheless its SY1Dptomatology may be lacking-which explains why it is seldom recognised during life -and that perforation into the peritoneal cavity may be included among tho immediate causes of death in pulmonary tuherculosis. Ulcerative enteritis, always secondary to pulmonary tuberculosis, may be suspected in cases of abdominal pain and intractable diarrhroa, radiology sometimes confirming the diagnosis. The point to which the writers wish to draw attention, however, is that in 3 per cont. of pulmonary tuberculosis cases an intestinal perforation may be seen on careful post-mortem examination. The perforation may be singlo or multiple, and though most frequently seen at the end of the ileum, it may occur at any part of the small intestine and even in the colon. A paradoxical fact in this connection is that \vhile there must always be in such cases a mom or less abundant purulent or fro cal fluid in the peritoneal cavity, yet the peritoneal reaction to the perforation is minimal, the organism of the patient doubtless being unable to put up any defence. The floor of the ulceration is astonishingly thin, so much so that it is a matter· for surprise that perforation does not occur more often. Clinically, perforation mny be evidenced in two different ways: suddenly, with the signs of an acute peritonitis, or it may be of tho latent, asthenic type in which tho general condition becomes rapidly worse, dyspnroa and cyanosis increase, the pulse becomes uncountable without any abdominal signs, death taking place in a few hours, or more rarely in two or three days. Nine of the 12 ea"es in the writers'