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A NOTE ON MULTIPLE SUPERFICIAL ULCERS OF THE SMALL INTESTINE.
16 At operation the faecal mass was found to be between 5 and 6 in. in width. No cause could be found for the obstruction ; the pelvic colon below the mass seemed to be quite normal to sight and palpation. A colostomy was made by introducing a Paul’s tube into the transverse colon, just proximal to the mass. For some weeks after operation attempts were made to evacuate the impacted mass by enemas of all kinds, but without success. Instead there was a steady increase of pain and tenderness localised to the left iliac fossa, associated with fever and emaciation. These symptoms persisted for three months. The next event was the birth, without serious difficulty, of a healthy eight-months child. After labour the bowels opened naturally, with the evacuation of hard masses, in which fruit-stones were conspicuous. At this time about one-third of the faecaloma came away, with temporary relief of pain and fever. No further evacuation occurred, and pain and fever returned during the puerperium. The symptoms were very severe indeed, and lasted about six weeks. During this time the lower abdomen was very tender to palpation, especially on the left side. Micturition was frequent and painful. By vaginal examination, a large inflammatory mass could be felt in the left fornix. After all symptoms had subsided completely, the faecal mass was finally and rapidly evacuated by the introduction of a saturated solution of magnesium sulphate into the distal limb of the colostomy.
I
In April, 1927, the abdomen was reopened. The pelvic colon was found to be only a few inches in length, was narrowed, very hard and fibrous, and united by recent adhesions to the body of the uterus. Above this stricture the descending’ colon was enormously dilated and somewhat hypertrophied.
As the stricture reached the upper end of the rectum, any attempt at resection and anastomosis was out of the question. The colostomy was therefore excised and the free extremities anastomosed side to side. This was followed by a complete return to health. The bowels continue to act regularly as a result of the copious daily use of magnesium sulphate. Annapolis, Brazil. A NOTE
Smears made from scrapings of the bases and edges of ulcers, and of their peritoneal surface, showed no tubercle bacilli. Unfortunately, the ulcers were not histologically examined, but in view of the findings in the next two cases, it is probable that the histological picture would havebeen A history of pain in similar to that described below. abdomen and diarrhoea of four months’ duration was obtained from the brother. CASE 2.-On July 28th, 1927, a young male Tamil was admitted to the hospital with complaint of passing loose motions, five to seven times a day, without blood or mucus, for about a fortnight. He died on August 10th and autopsy revealed only nine small superficial ulcers in upper part of jejunum. A few ulcers were circular ; but most of them were oval with their longer diameter in the transverse axis The peritoneal surface of these ulcers was of bowel. puckered. No protozoa or acid-fast bacilli were found in smears. Cultures yielded coliform organisms. The rest of the alimentary canal was normal, and no evident cause of death other than the ulcers was noted. The body was emaciated, and it is likely that the illness was of longer duration than indicated by the history. Sections of the ulcers showed chronic inflammatory changes with loss of the mucous and submucous coats. CASE 3.-A Tamil, aged 30, was admitted to the hospital on June 19th, 1927, suffering from chronic urethritis, and progressive emaciation and diarrhoea. The Wassermann Intestinal tuberculosis was susreaction was negative. pected. He died on August 20th, and autopsy revealed transverse ulcerations along the whole length of the small intestine extending from the lower third of the duodenum to 2 feet from the ileocsecal junction, with four to five ulcers in each foot of intestine. The description already given to those in Case 1 applies equally to these. Sections showed no histological evidence of tuberculous condition. There was loss of mucous and submucous coats and evidence of chronic inflammation.
These three cases present an unusual type of ulceration of the small intestine. The ulcers were superficial and showed a tendency to healing and scarring. No explanation of the genesis of these ulcers can at present be given. So rare is the condition that a diagnosis antemortem must be extremely difficult. Radiographic examination of the small intestine might help in diagnosis. The anatomical resemblance to tuberculous lesion suggests that the ulceration extends transverselv round the gut by following the course of lymphatics and bloodvessels ; but the lymphoid nodules do not appear to be involved, as they are in typhoid and tuberculous ulcers.
ON
MULTIPLE SUPERFICIAL ULCERS OF THE SMALL INTESTINE. BY K. KANAGARAYER, L.M.S. SINGAPORE, D.T.M. BENGAL, ASSISTANT BACTERIOLOGIST, INSTITUTE FOR MEDICAL RESEARCH, KUALA LUMPUR, FEDERATED MALAY STATES.
DONATIONS AND BEQUESTS.—Sir Henry James Hall, AMONG ulcers of the small intestine, the single Charlwood, Surrey, left i51000 to St. Dunstan’s Gloverswood, duodenal ulcer, the multiple typhoid ulcers of the for Blinded Sailors and Soldiers, and £500 to the Hospital ileum and lower alimentary tract, and tuberculous London Association for the Blind.—Mr. Frank Sussum, of ulcerations have all been classified and descriptively Cambridge, left i51000 to Addenbrooke’s Hospital. CamIn 3000 autopsies during the last four bridge.—Mr. Ramsay Paxton, of Sunderland, left £700 each labelled. years I have found, in three cases, an ulceration of the to Sunderland Infirmary and Sunderland Orphan Asylum.— small intestine which fails to conform to any of those Among other bequests Mr. F. L. Heyn, T.P.. of Craigavad, three recognised types. As attention has been County Down, left £1000 to the Royal Victoria Hospital, to name two beds, one to be called the Frederick directed to a similar condition in a case reported by Belfast, L. Heyn and Helen B. Heyn Bed," and the other the M. Scott and J. B. Cleland,1 the post-mortem findings ’’ F. L. Heyn Head Line of Steamers Bed " : £250 to the in these three cases are here briefly recorded. Belfast Maternity Hospital: .S250 to the Society for Provid"
,
Reports of
Cases.
CASE 1.—On Jan. 26th, 1925, the body of a Tamil, said to have committed suicide by hanging, was brought to the District Hospital, Kuala Lumpur. Its condition suggested that a chronic wasting disease had driven him in desperation to take his life. At autopsy the only lesions were a series of superficial ulcerations in the small intestine extending from 1 inch from the duodeno-jejunal flexure to 4 feet from the ileocsecal junction. There were four or five ulcers in each foot of intestine, all running transversely, and the majority involving the entire circumference of the bowel. Some of them were quite narrow, others inch in diameter. The base was fairly smooth, and the edges only slightly raised. The peritoneal surface was not thickened in most cases, but a few showed slight puckering. In their distribution, serpiginous extension in the transverse axis of the bowel, and puckering of the peritoneal surface, they almost resembled tuberculous lesions, except that there was less puckering, edges and bases were less ragged, and tubercles on the peritoneal surface were absent. There, was no evidence of tubercle in the abdomen or elsewhere. 1
Medical Journal of Australia, 1927, i., 718.
ing Nurses for the Sick Poor of Belfast ; £200 each to the Samaritan Hospital, Belfast, and the Ulster Hospital for Women and Children, Belfast.-Under the will of Sir Edwin Evans, J.P., of Battersea, the Bolingbroke Hospital, Wandsworth Common, S.W., will receive £1000 for general purposes and the Battersea General Hospital and the Royal Blind Pension Society of the United Kingdom i5230 each.—Mr. Samuel Kidd, of Derby-road, Farnworth, near Widnes. left £1000 each to the School for the Blind, Hardman-street. Liverpool, the Royal Infirmary. Liverpool, the Eye and Ear Infirmary, Liverpool, and the Ethel Gossage Home. Farnworth Branch.—Mr. Matthew Turbitt, of Birkdale, Southport, left £1000 stock to the Southport Infirmary and, subject to a life interest, ’ .61000 each to the Imperial Cancer Research Fund, Dr. Barnardo’s Homes, the Church Army, the National Lifeboat Institution, and the North of England Children’s Sanatorium at Southport. After other bequests the ultimate residue of the property will be divided between St. Dunstan’s Hostel for the Blind, King George’s Fund for Sailors, the Society for the Prevention of Cruelty to Children. the Royal Association in Aid of the Deaf and Dumb, the Southport and District Deaf and Dumb Mission, and the Southport and Birkdale Provident Society.
I
In April, 1927, the abdomen was reopened. The pelvic colon was found to be only a few inches in length, was narrowed, very hard and fibrous, and united by recent adhesions to the body of the uterus. Above this stricture the descending’ colon was enormously dilated and somewhat hypertrophied.
As the stricture reached the upper end of the rectum, any attempt at resection and anastomosis was out of the question. The colostomy was therefore excised and the free extremities anastomosed side to side. This was followed by a complete return to health. The bowels continue to act regularly as a result of the copious daily use of magnesium sulphate. Annapolis, Brazil. A NOTE
Smears made from scrapings of the bases and edges of ulcers, and of their peritoneal surface, showed no tubercle bacilli. Unfortunately, the ulcers were not histologically examined, but in view of the findings in the next two cases, it is probable that the histological picture would havebeen A history of pain in similar to that described below. abdomen and diarrhoea of four months’ duration was obtained from the brother. CASE 2.-On July 28th, 1927, a young male Tamil was admitted to the hospital with complaint of passing loose motions, five to seven times a day, without blood or mucus, for about a fortnight. He died on August 10th and autopsy revealed only nine small superficial ulcers in upper part of jejunum. A few ulcers were circular ; but most of them were oval with their longer diameter in the transverse axis The peritoneal surface of these ulcers was of bowel. puckered. No protozoa or acid-fast bacilli were found in smears. Cultures yielded coliform organisms. The rest of the alimentary canal was normal, and no evident cause of death other than the ulcers was noted. The body was emaciated, and it is likely that the illness was of longer duration than indicated by the history. Sections of the ulcers showed chronic inflammatory changes with loss of the mucous and submucous coats. CASE 3.-A Tamil, aged 30, was admitted to the hospital on June 19th, 1927, suffering from chronic urethritis, and progressive emaciation and diarrhoea. The Wassermann Intestinal tuberculosis was susreaction was negative. pected. He died on August 20th, and autopsy revealed transverse ulcerations along the whole length of the small intestine extending from the lower third of the duodenum to 2 feet from the ileocsecal junction, with four to five ulcers in each foot of intestine. The description already given to those in Case 1 applies equally to these. Sections showed no histological evidence of tuberculous condition. There was loss of mucous and submucous coats and evidence of chronic inflammation.
These three cases present an unusual type of ulceration of the small intestine. The ulcers were superficial and showed a tendency to healing and scarring. No explanation of the genesis of these ulcers can at present be given. So rare is the condition that a diagnosis antemortem must be extremely difficult. Radiographic examination of the small intestine might help in diagnosis. The anatomical resemblance to tuberculous lesion suggests that the ulceration extends transverselv round the gut by following the course of lymphatics and bloodvessels ; but the lymphoid nodules do not appear to be involved, as they are in typhoid and tuberculous ulcers.
ON
MULTIPLE SUPERFICIAL ULCERS OF THE SMALL INTESTINE. BY K. KANAGARAYER, L.M.S. SINGAPORE, D.T.M. BENGAL, ASSISTANT BACTERIOLOGIST, INSTITUTE FOR MEDICAL RESEARCH, KUALA LUMPUR, FEDERATED MALAY STATES.
DONATIONS AND BEQUESTS.—Sir Henry James Hall, AMONG ulcers of the small intestine, the single Charlwood, Surrey, left i51000 to St. Dunstan’s Gloverswood, duodenal ulcer, the multiple typhoid ulcers of the for Blinded Sailors and Soldiers, and £500 to the Hospital ileum and lower alimentary tract, and tuberculous London Association for the Blind.—Mr. Frank Sussum, of ulcerations have all been classified and descriptively Cambridge, left i51000 to Addenbrooke’s Hospital. CamIn 3000 autopsies during the last four bridge.—Mr. Ramsay Paxton, of Sunderland, left £700 each labelled. years I have found, in three cases, an ulceration of the to Sunderland Infirmary and Sunderland Orphan Asylum.— small intestine which fails to conform to any of those Among other bequests Mr. F. L. Heyn, T.P.. of Craigavad, three recognised types. As attention has been County Down, left £1000 to the Royal Victoria Hospital, to name two beds, one to be called the Frederick directed to a similar condition in a case reported by Belfast, L. Heyn and Helen B. Heyn Bed," and the other the M. Scott and J. B. Cleland,1 the post-mortem findings ’’ F. L. Heyn Head Line of Steamers Bed " : £250 to the in these three cases are here briefly recorded. Belfast Maternity Hospital: .S250 to the Society for Provid"
,
Reports of
Cases.
CASE 1.—On Jan. 26th, 1925, the body of a Tamil, said to have committed suicide by hanging, was brought to the District Hospital, Kuala Lumpur. Its condition suggested that a chronic wasting disease had driven him in desperation to take his life. At autopsy the only lesions were a series of superficial ulcerations in the small intestine extending from 1 inch from the duodeno-jejunal flexure to 4 feet from the ileocsecal junction. There were four or five ulcers in each foot of intestine, all running transversely, and the majority involving the entire circumference of the bowel. Some of them were quite narrow, others inch in diameter. The base was fairly smooth, and the edges only slightly raised. The peritoneal surface was not thickened in most cases, but a few showed slight puckering. In their distribution, serpiginous extension in the transverse axis of the bowel, and puckering of the peritoneal surface, they almost resembled tuberculous lesions, except that there was less puckering, edges and bases were less ragged, and tubercles on the peritoneal surface were absent. There, was no evidence of tubercle in the abdomen or elsewhere. 1
Medical Journal of Australia, 1927, i., 718.
ing Nurses for the Sick Poor of Belfast ; £200 each to the Samaritan Hospital, Belfast, and the Ulster Hospital for Women and Children, Belfast.-Under the will of Sir Edwin Evans, J.P., of Battersea, the Bolingbroke Hospital, Wandsworth Common, S.W., will receive £1000 for general purposes and the Battersea General Hospital and the Royal Blind Pension Society of the United Kingdom i5230 each.—Mr. Samuel Kidd, of Derby-road, Farnworth, near Widnes. left £1000 each to the School for the Blind, Hardman-street. Liverpool, the Royal Infirmary. Liverpool, the Eye and Ear Infirmary, Liverpool, and the Ethel Gossage Home. Farnworth Branch.—Mr. Matthew Turbitt, of Birkdale, Southport, left £1000 stock to the Southport Infirmary and, subject to a life interest, ’ .61000 each to the Imperial Cancer Research Fund, Dr. Barnardo’s Homes, the Church Army, the National Lifeboat Institution, and the North of England Children’s Sanatorium at Southport. After other bequests the ultimate residue of the property will be divided between St. Dunstan’s Hostel for the Blind, King George’s Fund for Sailors, the Society for the Prevention of Cruelty to Children. the Royal Association in Aid of the Deaf and Dumb, the Southport and District Deaf and Dumb Mission, and the Southport and Birkdale Provident Society.