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Intestinal tuberculosis
INTESTINAL TUBERCULOSIS,l By A,~sislallt
JA~IES :MAXWELL,
PhysicialZ, St. Ba rihololllew's
M.D., F.R.C.P.
llo'~Jlil(/l;
Physiciall, Royal Chest Hospital,
LOIZ!101Z.
THE term "Intestinal Tuberculosis" is used, in a comprehensive manner to include a variety of different pathological and clinical states. In order to approach the subject from the point of view of the clinician, which is the chief object of this communication,it is first necessary to have a clear idea of the different varieties which may exist, and the logical approach to this aspect of the subject is by means of a pathological study. For this reason, the post-mortem records of the Hoyal Chest Hospital and St. Bartholomew's Hospital have been investigated and I am indebted to Dr. J. S. Cookson, recently House Physician at the Hoyal Chest Hospital, for much valuable' help in this study. '1'he series of cases under review was found in the course ofa survey of 8,087 routine post-lllortem examinations carried out during the past twenty-five years. Pulmonary tuberculosis, in varying grades of activity, was present in 785 cases, and intestinal tuberculosis, of one kind or another, was noted on 233 occasions. In the great majority of cases of intestinal tuberculosis, pulmonary disease was also present, and the ratio of intestinal to pulmonary tuberculosis was approximately 29 per cent. ' A very superficial study of this series was suflicient to show that the variety of intestinal lesions is such that some ROrt of pathological classification is essential and the following appears to be satisfactory. TYPES OF INTESTI~AL TUBERCULOSIS,
1. 2.
Nodular Ulcerative
3. 4. 5. 6.
Hyperplastic. Lymphatic. Adhesive. Extrinsic.
.. l
.. J
Superficial •. Subperitoneal ..
(a) Simple. (b) With Pulmonary Tuberculosis . { (c) With ~IiIiary Tuberculosis.
In the first place, a study of the age incidence shows that there are two well-defined peaks, the first oCUl'l'ing in the first five years of life, and the second in young adults (Table I). TADL})
I.-AGE
I:>CIDE!-OCE OF INrE5TI~AL TUBEltCGLOSIS.
Ages
,\~es
0- 5 6-10 11-15 16-20 21-25 2G-30 31-35
45 11
24
35 27 27
l(J
36-40, 41-45 4G-50 51-55 5G-GO GI-G5 GG-70
Cil:ie:i
12 10 7 '7 5 3 1
, The peak in early childhood occurs at the age when miliary tuberculosis is rampant, and the second peak, spread over a considerably wider 1
A paper read at the :\Ieeting of tJle Tuberculosis Association, held on January 17, 1936.
22
338
[May, 1936
'l'UDEIWLE
age period, corresponds with the known.incidence of the more acute forms of pulmonary tuberculosis. 'rhus it would seem that intestinal tuberculosis can occur in the course of the two commonest varieties of fatal tuberculous infection. In view of this fact, the cases have been separated into two groups, the fil;St consisting of children up to the age of 15 years and the second of cases over that age, the first group containing most of the miliary cases and the second the majority of the pulmonary cases. 'l'he sex incidence in children undel' the age of 15 was 41 males and 39 females. In the older group there were 105 males and ,18 females, but post-mortem statistics are such a hazardous guide in many respects that it cannot be deduced that the preponderance of males results from any cause other than the known greater incidence of the disease in males. It will be noticed that in the classification suggested the term "secondary," which is commonly employed by most writers on the subject, has been abandoned. This has been done because the use of the temt" appears to involve an assumption ,,;hich is not strictly justified by the known facts and which is of no importance to the clinician. '1'he series of cases which has been considered here has been analysed in terms of this classification and the association of intestinal tuberculosis with pulmonary tuberculosis and with miliary tuherculosis is clearly indicated ('rable II). TADLE H.-ANALYSIS OF A SEnIES OF :!33 CASES OF IXTESTINAL TUBERCULOSIS. .\<1,,11.
Nodular •• Ulcerativc Hyperplustic Lymphatic "\dhcsivc Extrinsic
Simplo ., " With PulmoDary Tuberculosis With lIliliary Tuberculosis ., Simple.. •• With Pulmonary Tuberculosis With lIliliary Tubcrculosis •.
2
9
2
G
105 12 2 3 11 1
Chiluren
'i
2
G 9
23
:!G 0 5 1
1
Total
}
28
}181
2 8 12 2
The description of the· cases as found in the' post-mortem records emphasises!1 {act which must be clearly remembered, that the pathology of tuberculosis in the bowel is exactly comparable to the pathology of tuberculous inflammation affecting any other structure and, in fact, the resemblance is particularly sti:iking when the lesions are compared with those of pulmonary tuberculosis. Thus there are records of miliary tubercles, nodular caseating' areas, ulcer formation, and attempts at healing as shown by fibrosis. In addition, the other evidences of inflammation, hyperromia, swelling of lymphoid follicles and superficial erosions, were present in many cases. Nodular lesions noted in these cases exemplified the usual types of tuberculous inflammation. Thus there were simple swellings of the Peyer's patches, typical small grey miliary tubercles situated either in the mucosa. or underneath the peritoneuIll, and larger yellowish caseating nodules, strictly comparable to those found in the lung in the more chro!Jic stages of the disease. In all, these lesions were present in 28 of the cases. In some the
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INTESTINAL '!'UIlEHCULOSIS
330
miliary nature of the lesions showed clearly that the condition was of very recent onset; this condition was present in eight cases, two adults and six children, and formed part of a generalised tuberculosis. In 11 cases, nine adults and two children, the lesions appeared to be somewhat less acute and these were all associated with active pulmonary disease. It would appear that they were in fact a pre-ulcerative stage which would have progressed to the fully developed condition had the patients lived. In the remaining nine cases a simple nodular tuberculosis was present without ar,ty evidence of lung disease and, in fact, without any evidence that the infection was associated with any other tuberculous lesion. ~'hese appear to be true" primary" cases. The separation of this group appears to be important in that it indicates the earliest stage of intestinal tuberculosis and it is desirable to realise that ulceration is not invariably a part of the pathological picture. In some cases, undoubtedly, ·the caseous lesions were sufficiently chronic to make it clear that there was little tendency to ulceration and that death had resulted from tuberculous toxromia. The cases in which ulceration was present have been classified upon exactly the same principle as the nodular group. By far the majority, 105 adults and 23 children, were associated with active pulmonary tuberculosis, but 38 cases (12 adults and 2G children) were associated with miliary tuberculosis, and 15 cases (6 adults and 0 children) were apparently" primary." \Vhile it is obvious that the known close association of pulmonary and intestinal tuberculosis is borne out by these figures, yet it must be noted that a by no means insignificant proportion of the cases was not associated \vith active pulmonary disease, and this matter will be further considered when the causation of intestinal ulceration is discussed. The two foregoing groups of cases, which include 209 out of the total series of 233, can be classed together in that they form a definite group of lesions which merge imperceptibly from the earliest miliary tubercle to the established tuberculous ulcer. The cases in the remaining groups are much fewer in number, and illustrate how comparatively rare are the other-forms of intestinal tuberculosis. Hyperplastic tuberculosis of the cmcum was only found in two cases. ~lhis result must be held to indicate the fallacy of post-mortem statistics, for the condition is generally held to be considerably more frequent than is suggested by these figures. ~'he term "lymphatic type" is employed to designate those cases in which the actual intestinal wall is not primarily affected but has become invol ved in a lUass of caseous glands. 'l'his may result either in obstruction to the bowel or in perforation of the wall of the gut with resultant secondary ulceration or even with frocal abscess formation. ~'his type was present in eight cases altogether. ~'he glands affected were, in each case, those which drain the bowel. ~'he " adhesive type" is not very uncommon and appears neady always to affect adults (11 adults and 1 child). rl'he infection in these cases appears to involve chiefly the peritoneal surface of the bowel, spreading either from infected glands or from inflammation of surrounding strllctures~mostcommonly the Fallopian tubes. In these cases, again,
[1\Iay, 1936
TUBKHCLE
3-10
the clinical picture is likely to be that of intestinal obstruction or of local peritonitis. The term "extrinsic type" is employed to indicate those cases in which the abdominal cavity has been involved by direct spread from an extra-abdominal site. The only two cases in this group resulted from hip disease in which pus had tracked within the abdominal cavity. Similar cases have been known to arise as the result of spread from the spine in Pott's disease or even from tuberculous empyema. From the clinician's point of view, the essential feature is to realjse that tuberculous disease of the intestine, although commonly associated with pulmonary tuberculosis, may be associated with other types of tuberculous disease, or may even be primary. An indication is therefore obtained as to the necessary routine method which should be adopted in the clinical study of all cases. The distribution of the ulcerative and nodular lesions is indicated in Table III. TABLE IlL-SITES OF LESIONS IN IN"TESTINAL TUBERCULOSIS.
(Esophagus Stomach Duodenum Jejunum Ileum .. Appendix C:Bcum •• Colon Rectum .,
1
3
8
66
174
6 108 93
15
The part most commonly affected is the lower end of the ileum and the crecum, and lesions are found progressively" less commonly towards either end of the alimentary tract. These figures are entirely in agreement with all the other published series and do not need special discussion. It is noteworthy that the appendix is only stated to be involved in six cases, an incidence which is much less common than has been found in other series. It is probable that the state of the appendix was not noted sufficiently carefully in this series, as it seems urrlikely that this discrepancy results from a true variation in the incidence of the condition. In order to complete the pathological study certain additional lesions must be considered. Of the other abdominal conditions which must be noted, it was found that local lymphatic glands were affected in 108 cases, the majority of the infections, of course, being clearly secondary to intestinal lesions. Gross peritoneal adhesions were present in 69 cases, in most of which the involvement was with underlying intestinal lesions; and it must be noted th\lt the great omentum was infiltrated in 33 cases. In addition, amyloid change was found to be present in 10 cases. The condition of the lungs has already been sufficiently indicated. The state of the upper respiratory tract is worthy of notice. Ulceration was found in the trachea in 22 cases (18 adults and 4 children) and in the larynx in 44 cases (138 adults and 6 children). It is not necessary to report in detail the results of a study of the state of the other organs, so many being involved as the result simply of
May, U136]
IN'fESTINAL TUBERCULOSIS
341
miliary tuberculosis. It may be stated, however, that the kidneys were found to be tuberculous in 39 cases, the Fallopian tubes in 4, the tonsils in 2 and Pott's c1isease was present in 1 case. COMPLICATIONS.
The three chief complications of intestinal tuberculosis are perforation, fmcal abscess formation and intestinal obstruction. Perforation of the bowel was found to have occurred in 17 cases, in 9 of which there was general peritonitis and in the remainder localised fmcal abscess; in two of the cases perforation had occurred immediately above the stricture, in the remainder perforation was through the base of an ulcer. '1'he site of rupture was most commonly in the ileum (11 cases), and the cmcum was involved in 3 cases; the appendix, transverse colon and rectum on one occasion each. Intestinal obstruction was found to have occurred in 7 cases. It resulted invariably from dense adhesions distorting the bowel. No instance of obstruction due to stricture fo·rmation was discovered. The chief complications may be tabulated as follows : (1) A secondary infection, which results in the exacerbation of any symptoms which may be present and is the cause of high temperature. (2) Hmmorrhage, which is not usually profuse but may on occasion be fatal. (3) Stricture, which results either from healing ulcers or from the hyperplastic type of disease. This may lead to· clinical intestinal obstruction, but is not usually associated with pulmonary tuberculosis. -(4) Peritonitis, may be acute or chronic. In the acute form there may be a generalised tuberculous peritonitis or a slllall abscess in the region of a shut-off perforation. The extension of this process may lead to the formation of a fistula between the bowel and some other' viscus or the skin. Chronic peritonitis may be associated with effusion, but the commonest . type is that associated with adhesions which may be localised or gene'ralised. (5) Pelforation may occur either from rupture of the base of the ulcer or from the giving way of the distended bowel wall immediately above the site of the stricture. This invariably results in a localised or generalised peri toni tis. (6) Amyloid disease is a rare complication which usually results from secondary infection. (7) Generalised miliary tuberculosis is not uncommon and may stand in relation to the intestinal lesion either as cause or effect. Frolll the clinical and prognostic points of view this relationship is immaterial. (8) Intussllsception has been described on occasion. It may occur as. a post-mortem phenomenon, and its exact frequency is not known. CAUSATION OF INTESTINAL TUBERCULOSIS.
It has .already been stated that the lesions in intestinal tuberculosis are strictly comparable to those elsewhere in the body. The chief source of contention has been the route by which the infection reaches the boweL There are obviously three possibilities: direct contact, the blood stream
342
TUBERCLE
[l\Iay, 1936
and the lymphatics. Animal experiment, as so often happens, has proved inconclusive, for it has been found difficult to infect the intestinal tract in a healthy animal as the result of the ingestion of known tuberculous material or of virulent tubercle bacilli. Carefully conducted experiments have shown that a positive result is much more likely to be obtained if the animal is in poor condition, and particularly if there has been lack of balance in the intake of vitamins A, C and D. In addition to this, a deficient supply of calcium in the diet appears to be a factor in production. Parenteral introduction of tubercle bacilli either into the blood stream or into the sub-cutaneous tissues has been successful in producing intestinal lesions in a number of cases, and on the whole this route appears to have been more successfully employed than the direct method. At the same time, the results in neither series of experiments appear to be at all convincing. The results of a pathological study are at least as illuminating. In the first place, the common association between active ulcerative lesions in the lungs and in the intestinal tract suggests that the conditions occur simultaneously in a patient who is unable adequately to resist infection. In other words, intestinal tuberculosis appears to be a common complication of actively progressive pulmonary disease and, in fact, the figures show that it is even more common than laryngeal tuberculosis, which is admitted to occur in those who are resisting the infection badly. In active pulmonary tuberculosis there are always very numerous tubercle bacilli in the sputum and therefore there is ample opportunity for direct contact to occur. In the great majority of cases in which the pulmonary disease has become quiescent, bacilli are still being swallowed and contact is occurring, but the resistence of the patient is such that the intestinal tract does not as a rule become infected. It is known that tubercle bacilli may pass through the wall of the intestine leaving no visible lesion, and it is probable tbat the primary glandular infection occurs in this way. At the same time, the figures quoted in this series show clearly that intestinal lesions, both nodular and ulcerative, occur in quite a significant proportion of cases in which the presence of miliary tuberculosis indicates the existence of a blood-stream infection, and in most of these cases active lung lesions are not present. From this it seems reasonable to deduce that intestinal ulceration may occur as the result of a blood-stream infection. In fact, as is the explanation in the majority of cases when rival theories are put forward to explain the causation of a disease condition, it seems probable that both explanations are correct in different cases. It is very difficult to explain why the stomach is not more commonly affected. It has been suggested that the immunity of. the stomach is the result of its protective acid secretion, yet it is a known' clinical fact that in many cases of advanced tuberculosis, a greatly diminished secretion of acid is present. It has also been suggested that the comparative stasis of the intestinal contents in the region of the low~r ileum and crecum makes for prolonged contact of the bacilli with the bowel in this region. It seems obvious, however, that the chief difference between the stomach and the regions most commonly affected is the comparative absence 'of lymphoid tissue in the former organ; and, as lymphoid tissue is that most commonly
l\Iay, 1936]
INTESTINAL TUBERCULOSIS
343
involved in the disease, the relative imlUunity of the stomach might reasonably be attributed to this fact. SU)DIARY OF PATHOLOGY.
In cases in which the infection reaches the mucous membrane by direct contact, the initial lesions are usually in the lymphoid tissue. 'l'here is initial sweIling with hypenelllia, and it is possible that some lesions may subside from this stage. In the majority of cases, however, the disease advances and the next stage is one of caseation. At this stage one of the varieties of nodular tuberculous disease is present. In most of these cases the superficial epithelium is then shed and the typical tuberculous ulcer results. This is at first a shallow lesion with ragged, undermined and very often cedematous edges. Although it is usually stated that tuberculous ulcers are situated transversely to the long axis of the bowel, this is not by any means always the case; many are circular and many are -longitudinal, and these can only be differentiated macroscopicaIIy from typhoid ulcers by the absence of tubercles on the peritoneal surface. In most cases there is some attempt at healing and this may be shown by fibrosis and thickening either in the margins or at the base of the ulcer. rrhis process usually results in a protection of the base and to a large extent guards against the risk of perforation. In some cases the healing process proceeds almost to completion by fibrosis, and fibrous stricture of the bowel may result. As is shown in this series, however, this event is comparatively rare. It is more common to see evidence of healing and cicatrisation in some parts of ulcers which are showing signs of activity in other directions. \Vhen stenosis does occur, the strictures are usually multiple, although spastic strictures have been described. Stenosis is much commoner with pure intestinal tuberculosis, the reason being that in cases associated with active pulmonary disease the patient does not usually survive long enough for sufficient fibrosis to occur. Ulcers which are ragged and serpiginous are usuaIIy the result of a secondary infection. Tuberculosis has a tendency to spread by lymphatics, and· the regional glands are found to be commonly involved. It is stated that this occurs when the small intestine is affected, but is rare when the ulceration is confined to the colon. . Although these are the changes which are commonly noticed, it must be remembered that there are more diffuse changes found on microscopical examination. Not only may there be a diffuse hyperremia and round-celled infiltration of the whole wall of the intestine, but also there is a tendency for both of the nerve plexuses to be affected and it is thought that this disturbance of the nervous control of the bowel may be really responsible for the production of such symptoms as pain and diarrhcea. As has already been stated, it seemed probable that infection by contact and infection from the blood stream are both common causes of the condition. It is·difficult to explain why the blood-·stream infections should pick out the ileum andcrecum, yet the evidence in favour of blood-stream infections in a considerable proportion of the cases is such that it is impossible to ignore its existence. 'Vith regard to the ulceration which
TUDEHCLE
[May, HJ3G
accompanies active pulmonary tuberculosis, it is found that the activity of the ulceration is roughly proportional to the activity of the lung lesion as shown by the existence of recent cavitation and by large numbers of tubercle bacilli in the sputum. CLI~ICArJ FEATURES.
Symptoms.-Tuberculosis is notorious for the diversity of its symptoms and the intestinal type is no exception to this rule. 'l'here may be little or no abdominal discomfort in the presence of advanced disease and, conversely, there may be symptoms which point plainly to the intestinal tract incases in which at post-mortem there are no demonstrable lesions in any part of the bowel. l\Iost commonly in the early stages, there are slight digestive disturbances. A little discomfort after nwals, a feeling of fullness, occasional diarrhroa and constipation are very common and may be so slight that their significance is often overlooked. Commonly the patient feels unwell, as may be shown by an unexplained nervousness as to his condition, the weight shows a tendency to drop and there may be occasional slight pyrexia. A fairly characteristic feature of the complaint is a tendency to remissions. 'l'he more important and more definite symptoms must be considered separately. Pain is not by any means always present, nor is it an early symptom. It usually commences in the centre of the abdomen, but sooner or later radiates towards the right iliac fossa. Occasionally it is situated in" the epigastrium and it may have such a definite relation to meals that the presence of a gastric ulcer is suspected. It is usually most marked in the afternoon and may be accentuated by food. In a later stage the pain may be cramp-like or colicky. It is stated that a throbbing or burning sensation in the abdomen is associated with the presence of enlarged glands, and this may occur even when the mass has completely calcified. The reason for the pain is not clear. Severe ulceration may exist without any pain whatever and it is suggested hypermotilityand spasm are the usual causes. The pain is therefore seen to be associated more with muscle activity than with the"actual ulceration, and this in turn is thought to result from inflammatory involvement of the nerves in Meissner's plexus which is usually more involved than that of Auerbach. Diarrhroa, although it may be regarded as the classical symptom, is by no means the rule and there may even be marked constipation. "The onset of diarrhroa is often gradual and it commonly follows constipation. A frequent feature is the occurrence of remissions during which the bowel action may be practically normal. In many cases there is alternating diarrhroa and constipation. 'l'he cause of this diarrhroa may be either the increased peristaltic movements of the howel or diminished absorption of water and other products as a result of interference with blood" and lymph drainage. In some cases there lllay be very severe watery diarrhroa leading actually to clinical dehydration, the" intestinal sweats" of Graves. \Vhen ulceration occu~"s in the small intestine the prominent feature lllay be either diarrhcca or constipation, but with colitis
May, 1936]
INTESTINAL TUBERCULOSIS
345
diarrhooa is the rule. It is stated that constipation is associated ,.,.ith ulceration at the hepatic flexure of the colon. The number and situation of the ulcers, ho,vever, have no clear relation to the severity of the diarrhooa. This symptom may, in fact, be very marked when the only visible post-mortem change appears to be a simple catarrh of the mucous membrane. Tenesmus is only present in those cases in ,vhich the rectum is involved. Other abdominal symptoms of importance are nausea and vomiting. These are not very common but they may add to the difiiculty in diagnosis on occasion. They are usually associated with epigastric pain. rrhere may be considerable impairment of the appetite and distressing flatulence at times. . The temperature is very variable. In the majority of cases which prove fatal during the active stage of the disease there is a high. temperature which is usually remittent but, on occasions, the patient may be afebrile throughout the whole course of the disease. The most significant point in t.hose cases in which the condition complicates a known pulmonary tuberculosis is a temperature whieh remains raised while the pulmonary signs appear to indicate quiescence. In any case of phthisis in which there does not appear to be an adequate explanation for the temperature in the respiratory system a diagnosis of tuberculosis enteritis must be considered. . In rare cases, with very acute disease, there may be a typhoidal picture, and the differential diagnosis may depend upon serological reactions. Hremorrhage of any gross degree is rare. It may occur either from the small or from the large bowel and fatal cases have been described. As a rule, however, the intermittent passage of small quantities of blood is all that occurs. The weight falls very rapidly in most cases and an unexplained drop in weight has much the same diagnostic significance as an unexplained pyrexia. It must be remembered that many of the foregoing symptoms may be present without any demonstrable disease in the bowel. The symptoms are then thought to be toxic in origin and they undoubtedly result from a functional disturbance of the bowel mechanism. The existence of this type of symptom makes exact clinical diagnosis extremely difficult. Clinical examination is, as a rule, negative in character and beyond a localised "tenderness in those cases in which the peritoneum is involved there may be nothing "to be felt. Glandular masses and the hypertrophic type of disease cause lumps which are usually palpable. Rigidity is only present in those cases in which the inflammation is very acute, and is suggestive of perforation and local peritonitis. In most cases diagnosis must depend upon a consi~eration of the symptoms, a suspicion of the presence of tubercle, and the results of special investigations. INVESTIGATIONS.
Fmces.-The freces may appear normal on inspection, or loose stools may occur.. In very acute cases the freces may be watery and peculiarly
34G
TUllEHCLE
fretid. Visible blood llIay be present on occasion, and red blood-cells and pus lllay be detected under the microscope. ~'here is sometimes an excess of Cat in cases where the lymphatics are obstmcted. ,"Vhen there is extensive ulceration, occult blood is usualIy present. Examination of the stools Cor tubercle bacilli is frequently positive. "When there is known active pulmonary tuberculosis ,vith bacilIi in the sputum no significance can be attached'to this finding. In cases where there is no evidence of any pulmonary disease, the presence of tubercle bacilli in the stools is almost diagnostic of intestinal tuberculosis. Blood-examinations are not of much value. ~'here lllay be a severe secondary anromia, although this is not constant and there is usualIy a moderate "leucocytosis. A pernicious type of count has been recorded in cases of stricture of the smail bowel. 'rhe sedimentation rate is of no value in diagnosis and of little help in prognosis. EJldoscopic examination, by lUeans of the proctoscope or sigmoidoscope, mlty afford conclusive evidence when the lower part of the bowel is involved. It is of no value when the disease is located in the commoner sites. X-ray examination is not commonly practised in this country. " Its value has been stressed by IJawrason Brown and Samson in the United States and they emphasize the following points. "\Vhen a barium meal was given and followed at frequent intervals up to twelve hours they found localized areas of spasm in the region of the ulcers. "\Vhen the colon was involved they described a spastic filling defect which is usually permanent and suggests an organic alteration in the wall of the organ. Adhesions, as well as chronic tuberculous ulcers, also may produce a permanent alteration in the outline of the normal barium shadow. Intestinal huny is associated with active ulceration in the small bowel in some cases, but in atonic types of the disease and in early obstruction there may be marked retardation of the progress of "the meal. In cases where the mecum is involved, a barium enema may demonstrate constant spasm and the organ partially fills and empties; this condition of "intolerant crocum " appears to be fairly characteristic. ~'HEAT:'IENT.
'l'he prognosis IS usually regarded as being so bad that palliative measures are all that are considered as a rule. Attempts to achieve lUore permanent results have been made and must be considered if any improvement in our results is to" be obtained. Of course, the outlook is better when treatment is commenced in the early stages, and especially in those cases in which there is little or no pulmonary involvement. Cases in which miliary tuberculosis is present are invariably fatal and their treatment need not be considered. The first essential in treatment is prophylaxis. The patient should be instructed so far as possible not to swallow infected sputum. In addition it is desirable to give a mixture containing hydrochloric acid with meals and to give full doses of the main vitamins in all cases of active pulmonary tuberculosis. 'Vhen the presence of intestinal disease is established the first principle
l\Iay, H)3G]
INTESTINAL TUBBRCULOSIS
.347
of treatment is rest. The patient should be kept as still as possible and a cotton-wool pad over the abdomen is often of value in relieving discomfort. Exposure to chiIls must be carefuIly avoided. The diet must be carefully arranged. '1'he patient must avoid everything likely to cause intestinal movement, and cold drinks, milk, strong coffee, concentrated beef essences, fruit and salads should be avoided. In all cases it is desirable to avoid coarse, residue forming foods, and a low residue diet consisting of fruit juice, weak coffee, tea, cocoa, chocolate, white bread, jelly, eggs, and strained gruel should be advised. It is usually found that milk in large quantities is badly tolerated. As the clinical condition improves, thick soups, boiled fish, chicken, lean weat; potatoes, macaroni, purees and custards may be added to the diet, but all indigestible residue must be avoided. l\IacConkey advises cod-liver oil and orange juice or tomato juice in full doses and considers that the results of this treatment are beneficial. Drug treatment is not of great permanent value. ,Vhen dian-hooa is present bismuth or the old-fashioned astringents, such as kino or co to, a1:e often of value in checking this symptom. Calcium chloride given intravenously may be of considerable value not only in checking diarrhooa, but also in relieving pain which results from intestinal spasm. It is justifiable, in view of the good results of gold therapy in pulmonary tuberculosis, to give a course of sanocrysin, but the dosage should always be smaIl, starting \vith not more than 0·01 gram. In view of the good results obtained as a result of the induction of pneumoperitonenm in cases of tuberculous peritonitis with effusion, injections of oxygen have been employed in cases' of tubercular disease of the bowel and some success is claimed for this method. A much more promising method of treatment, however, is the use of heliotherapy. '1'he work of Hollier in Switzerland has emphasized the value of natural sunlight in most cases of non-pulmonary tuberculous disease. In most countries natural sunlight cannot be depended upon as a source of ray-therapy, and ultra-violet light (either fro111 mercury vapour or from carbon arc Jamps) has been extensively applied in the United States. The results are stated to be most encouraging, and it would appear that there is a field for the exploration of this line of treatment in this country. In cases where ultra-violet radiation has failed to effect improvement, some success has been claimed for X-ray therapy, but the reports are not convincing. Finally. in cases of localised abdominal disease, abdominal exploration may be undertaken. If the condition is sufficiently localised, excision may be practised, bilt if 'comparatively large area of bowel be involved in ulceration, then a short circuit may be performed. By this means rest of the affected part inay be achieved and healing may be encouraged, while obstructive symptoms may be overcome. It would appear from some of the published reports that the results of treatment in intestinal tuberculosis are more encouraging than have for a long time been supposed. Particularly is this the case with ultra-violet light therapy which might well be more extensively employed.
a
JA~IES :MAXWELL,
PhysicialZ, St. Ba rihololllew's
M.D., F.R.C.P.
llo'~Jlil(/l;
Physiciall, Royal Chest Hospital,
LOIZ!101Z.
THE term "Intestinal Tuberculosis" is used, in a comprehensive manner to include a variety of different pathological and clinical states. In order to approach the subject from the point of view of the clinician, which is the chief object of this communication,it is first necessary to have a clear idea of the different varieties which may exist, and the logical approach to this aspect of the subject is by means of a pathological study. For this reason, the post-mortem records of the Hoyal Chest Hospital and St. Bartholomew's Hospital have been investigated and I am indebted to Dr. J. S. Cookson, recently House Physician at the Hoyal Chest Hospital, for much valuable' help in this study. '1'he series of cases under review was found in the course ofa survey of 8,087 routine post-lllortem examinations carried out during the past twenty-five years. Pulmonary tuberculosis, in varying grades of activity, was present in 785 cases, and intestinal tuberculosis, of one kind or another, was noted on 233 occasions. In the great majority of cases of intestinal tuberculosis, pulmonary disease was also present, and the ratio of intestinal to pulmonary tuberculosis was approximately 29 per cent. ' A very superficial study of this series was suflicient to show that the variety of intestinal lesions is such that some ROrt of pathological classification is essential and the following appears to be satisfactory. TYPES OF INTESTI~AL TUBERCULOSIS,
1. 2.
Nodular Ulcerative
3. 4. 5. 6.
Hyperplastic. Lymphatic. Adhesive. Extrinsic.
.. l
.. J
Superficial •. Subperitoneal ..
(a) Simple. (b) With Pulmonary Tuberculosis . { (c) With ~IiIiary Tuberculosis.
In the first place, a study of the age incidence shows that there are two well-defined peaks, the first oCUl'l'ing in the first five years of life, and the second in young adults (Table I). TADL})
I.-AGE
I:>CIDE!-OCE OF INrE5TI~AL TUBEltCGLOSIS.
Ages
,\~es
0- 5 6-10 11-15 16-20 21-25 2G-30 31-35
45 11
24
35 27 27
l(J
36-40, 41-45 4G-50 51-55 5G-GO GI-G5 GG-70
Cil:ie:i
12 10 7 '7 5 3 1
, The peak in early childhood occurs at the age when miliary tuberculosis is rampant, and the second peak, spread over a considerably wider 1
A paper read at the :\Ieeting of tJle Tuberculosis Association, held on January 17, 1936.
22
338
[May, 1936
'l'UDEIWLE
age period, corresponds with the known.incidence of the more acute forms of pulmonary tuberculosis. 'rhus it would seem that intestinal tuberculosis can occur in the course of the two commonest varieties of fatal tuberculous infection. In view of this fact, the cases have been separated into two groups, the fil;St consisting of children up to the age of 15 years and the second of cases over that age, the first group containing most of the miliary cases and the second the majority of the pulmonary cases. 'l'he sex incidence in children undel' the age of 15 was 41 males and 39 females. In the older group there were 105 males and ,18 females, but post-mortem statistics are such a hazardous guide in many respects that it cannot be deduced that the preponderance of males results from any cause other than the known greater incidence of the disease in males. It will be noticed that in the classification suggested the term "secondary," which is commonly employed by most writers on the subject, has been abandoned. This has been done because the use of the temt" appears to involve an assumption ,,;hich is not strictly justified by the known facts and which is of no importance to the clinician. '1'he series of cases which has been considered here has been analysed in terms of this classification and the association of intestinal tuberculosis with pulmonary tuberculosis and with miliary tuherculosis is clearly indicated ('rable II). TADLE H.-ANALYSIS OF A SEnIES OF :!33 CASES OF IXTESTINAL TUBERCULOSIS. .\<1,,11.
Nodular •• Ulcerativc Hyperplustic Lymphatic "\dhcsivc Extrinsic
Simplo ., " With PulmoDary Tuberculosis With lIliliary Tuberculosis ., Simple.. •• With Pulmonary Tuberculosis With lIliliary Tubcrculosis •.
2
9
2
G
105 12 2 3 11 1
Chiluren
'i
2
G 9
23
:!G 0 5 1
1
Total
}
28
}181
2 8 12 2
The description of the· cases as found in the' post-mortem records emphasises!1 {act which must be clearly remembered, that the pathology of tuberculosis in the bowel is exactly comparable to the pathology of tuberculous inflammation affecting any other structure and, in fact, the resemblance is particularly sti:iking when the lesions are compared with those of pulmonary tuberculosis. Thus there are records of miliary tubercles, nodular caseating' areas, ulcer formation, and attempts at healing as shown by fibrosis. In addition, the other evidences of inflammation, hyperromia, swelling of lymphoid follicles and superficial erosions, were present in many cases. Nodular lesions noted in these cases exemplified the usual types of tuberculous inflammation. Thus there were simple swellings of the Peyer's patches, typical small grey miliary tubercles situated either in the mucosa. or underneath the peritoneuIll, and larger yellowish caseating nodules, strictly comparable to those found in the lung in the more chro!Jic stages of the disease. In all, these lesions were present in 28 of the cases. In some the
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INTESTINAL '!'UIlEHCULOSIS
330
miliary nature of the lesions showed clearly that the condition was of very recent onset; this condition was present in eight cases, two adults and six children, and formed part of a generalised tuberculosis. In 11 cases, nine adults and two children, the lesions appeared to be somewhat less acute and these were all associated with active pulmonary disease. It would appear that they were in fact a pre-ulcerative stage which would have progressed to the fully developed condition had the patients lived. In the remaining nine cases a simple nodular tuberculosis was present without ar,ty evidence of lung disease and, in fact, without any evidence that the infection was associated with any other tuberculous lesion. ~'hese appear to be true" primary" cases. The separation of this group appears to be important in that it indicates the earliest stage of intestinal tuberculosis and it is desirable to realise that ulceration is not invariably a part of the pathological picture. In some cases, undoubtedly, ·the caseous lesions were sufficiently chronic to make it clear that there was little tendency to ulceration and that death had resulted from tuberculous toxromia. The cases in which ulceration was present have been classified upon exactly the same principle as the nodular group. By far the majority, 105 adults and 23 children, were associated with active pulmonary tuberculosis, but 38 cases (12 adults and 2G children) were associated with miliary tuberculosis, and 15 cases (6 adults and 0 children) were apparently" primary." \Vhile it is obvious that the known close association of pulmonary and intestinal tuberculosis is borne out by these figures, yet it must be noted that a by no means insignificant proportion of the cases was not associated \vith active pulmonary disease, and this matter will be further considered when the causation of intestinal ulceration is discussed. The two foregoing groups of cases, which include 209 out of the total series of 233, can be classed together in that they form a definite group of lesions which merge imperceptibly from the earliest miliary tubercle to the established tuberculous ulcer. The cases in the remaining groups are much fewer in number, and illustrate how comparatively rare are the other-forms of intestinal tuberculosis. Hyperplastic tuberculosis of the cmcum was only found in two cases. ~lhis result must be held to indicate the fallacy of post-mortem statistics, for the condition is generally held to be considerably more frequent than is suggested by these figures. ~'he term "lymphatic type" is employed to designate those cases in which the actual intestinal wall is not primarily affected but has become invol ved in a lUass of caseous glands. 'l'his may result either in obstruction to the bowel or in perforation of the wall of the gut with resultant secondary ulceration or even with frocal abscess formation. ~'his type was present in eight cases altogether. ~'he glands affected were, in each case, those which drain the bowel. ~'he " adhesive type" is not very uncommon and appears neady always to affect adults (11 adults and 1 child). rl'he infection in these cases appears to involve chiefly the peritoneal surface of the bowel, spreading either from infected glands or from inflammation of surrounding strllctures~mostcommonly the Fallopian tubes. In these cases, again,
[1\Iay, 1936
TUBKHCLE
3-10
the clinical picture is likely to be that of intestinal obstruction or of local peritonitis. The term "extrinsic type" is employed to indicate those cases in which the abdominal cavity has been involved by direct spread from an extra-abdominal site. The only two cases in this group resulted from hip disease in which pus had tracked within the abdominal cavity. Similar cases have been known to arise as the result of spread from the spine in Pott's disease or even from tuberculous empyema. From the clinician's point of view, the essential feature is to realjse that tuberculous disease of the intestine, although commonly associated with pulmonary tuberculosis, may be associated with other types of tuberculous disease, or may even be primary. An indication is therefore obtained as to the necessary routine method which should be adopted in the clinical study of all cases. The distribution of the ulcerative and nodular lesions is indicated in Table III. TABLE IlL-SITES OF LESIONS IN IN"TESTINAL TUBERCULOSIS.
(Esophagus Stomach Duodenum Jejunum Ileum .. Appendix C:Bcum •• Colon Rectum .,
1
3
8
66
174
6 108 93
15
The part most commonly affected is the lower end of the ileum and the crecum, and lesions are found progressively" less commonly towards either end of the alimentary tract. These figures are entirely in agreement with all the other published series and do not need special discussion. It is noteworthy that the appendix is only stated to be involved in six cases, an incidence which is much less common than has been found in other series. It is probable that the state of the appendix was not noted sufficiently carefully in this series, as it seems urrlikely that this discrepancy results from a true variation in the incidence of the condition. In order to complete the pathological study certain additional lesions must be considered. Of the other abdominal conditions which must be noted, it was found that local lymphatic glands were affected in 108 cases, the majority of the infections, of course, being clearly secondary to intestinal lesions. Gross peritoneal adhesions were present in 69 cases, in most of which the involvement was with underlying intestinal lesions; and it must be noted th\lt the great omentum was infiltrated in 33 cases. In addition, amyloid change was found to be present in 10 cases. The condition of the lungs has already been sufficiently indicated. The state of the upper respiratory tract is worthy of notice. Ulceration was found in the trachea in 22 cases (18 adults and 4 children) and in the larynx in 44 cases (138 adults and 6 children). It is not necessary to report in detail the results of a study of the state of the other organs, so many being involved as the result simply of
May, U136]
IN'fESTINAL TUBERCULOSIS
341
miliary tuberculosis. It may be stated, however, that the kidneys were found to be tuberculous in 39 cases, the Fallopian tubes in 4, the tonsils in 2 and Pott's c1isease was present in 1 case. COMPLICATIONS.
The three chief complications of intestinal tuberculosis are perforation, fmcal abscess formation and intestinal obstruction. Perforation of the bowel was found to have occurred in 17 cases, in 9 of which there was general peritonitis and in the remainder localised fmcal abscess; in two of the cases perforation had occurred immediately above the stricture, in the remainder perforation was through the base of an ulcer. '1'he site of rupture was most commonly in the ileum (11 cases), and the cmcum was involved in 3 cases; the appendix, transverse colon and rectum on one occasion each. Intestinal obstruction was found to have occurred in 7 cases. It resulted invariably from dense adhesions distorting the bowel. No instance of obstruction due to stricture fo·rmation was discovered. The chief complications may be tabulated as follows : (1) A secondary infection, which results in the exacerbation of any symptoms which may be present and is the cause of high temperature. (2) Hmmorrhage, which is not usually profuse but may on occasion be fatal. (3) Stricture, which results either from healing ulcers or from the hyperplastic type of disease. This may lead to· clinical intestinal obstruction, but is not usually associated with pulmonary tuberculosis. -(4) Peritonitis, may be acute or chronic. In the acute form there may be a generalised tuberculous peritonitis or a slllall abscess in the region of a shut-off perforation. The extension of this process may lead to the formation of a fistula between the bowel and some other' viscus or the skin. Chronic peritonitis may be associated with effusion, but the commonest . type is that associated with adhesions which may be localised or gene'ralised. (5) Pelforation may occur either from rupture of the base of the ulcer or from the giving way of the distended bowel wall immediately above the site of the stricture. This invariably results in a localised or generalised peri toni tis. (6) Amyloid disease is a rare complication which usually results from secondary infection. (7) Generalised miliary tuberculosis is not uncommon and may stand in relation to the intestinal lesion either as cause or effect. Frolll the clinical and prognostic points of view this relationship is immaterial. (8) Intussllsception has been described on occasion. It may occur as. a post-mortem phenomenon, and its exact frequency is not known. CAUSATION OF INTESTINAL TUBERCULOSIS.
It has .already been stated that the lesions in intestinal tuberculosis are strictly comparable to those elsewhere in the body. The chief source of contention has been the route by which the infection reaches the boweL There are obviously three possibilities: direct contact, the blood stream
342
TUBERCLE
[l\Iay, 1936
and the lymphatics. Animal experiment, as so often happens, has proved inconclusive, for it has been found difficult to infect the intestinal tract in a healthy animal as the result of the ingestion of known tuberculous material or of virulent tubercle bacilli. Carefully conducted experiments have shown that a positive result is much more likely to be obtained if the animal is in poor condition, and particularly if there has been lack of balance in the intake of vitamins A, C and D. In addition to this, a deficient supply of calcium in the diet appears to be a factor in production. Parenteral introduction of tubercle bacilli either into the blood stream or into the sub-cutaneous tissues has been successful in producing intestinal lesions in a number of cases, and on the whole this route appears to have been more successfully employed than the direct method. At the same time, the results in neither series of experiments appear to be at all convincing. The results of a pathological study are at least as illuminating. In the first place, the common association between active ulcerative lesions in the lungs and in the intestinal tract suggests that the conditions occur simultaneously in a patient who is unable adequately to resist infection. In other words, intestinal tuberculosis appears to be a common complication of actively progressive pulmonary disease and, in fact, the figures show that it is even more common than laryngeal tuberculosis, which is admitted to occur in those who are resisting the infection badly. In active pulmonary tuberculosis there are always very numerous tubercle bacilli in the sputum and therefore there is ample opportunity for direct contact to occur. In the great majority of cases in which the pulmonary disease has become quiescent, bacilli are still being swallowed and contact is occurring, but the resistence of the patient is such that the intestinal tract does not as a rule become infected. It is known that tubercle bacilli may pass through the wall of the intestine leaving no visible lesion, and it is probable tbat the primary glandular infection occurs in this way. At the same time, the figures quoted in this series show clearly that intestinal lesions, both nodular and ulcerative, occur in quite a significant proportion of cases in which the presence of miliary tuberculosis indicates the existence of a blood-stream infection, and in most of these cases active lung lesions are not present. From this it seems reasonable to deduce that intestinal ulceration may occur as the result of a blood-stream infection. In fact, as is the explanation in the majority of cases when rival theories are put forward to explain the causation of a disease condition, it seems probable that both explanations are correct in different cases. It is very difficult to explain why the stomach is not more commonly affected. It has been suggested that the immunity of. the stomach is the result of its protective acid secretion, yet it is a known' clinical fact that in many cases of advanced tuberculosis, a greatly diminished secretion of acid is present. It has also been suggested that the comparative stasis of the intestinal contents in the region of the low~r ileum and crecum makes for prolonged contact of the bacilli with the bowel in this region. It seems obvious, however, that the chief difference between the stomach and the regions most commonly affected is the comparative absence 'of lymphoid tissue in the former organ; and, as lymphoid tissue is that most commonly
l\Iay, 1936]
INTESTINAL TUBERCULOSIS
343
involved in the disease, the relative imlUunity of the stomach might reasonably be attributed to this fact. SU)DIARY OF PATHOLOGY.
In cases in which the infection reaches the mucous membrane by direct contact, the initial lesions are usually in the lymphoid tissue. 'l'here is initial sweIling with hypenelllia, and it is possible that some lesions may subside from this stage. In the majority of cases, however, the disease advances and the next stage is one of caseation. At this stage one of the varieties of nodular tuberculous disease is present. In most of these cases the superficial epithelium is then shed and the typical tuberculous ulcer results. This is at first a shallow lesion with ragged, undermined and very often cedematous edges. Although it is usually stated that tuberculous ulcers are situated transversely to the long axis of the bowel, this is not by any means always the case; many are circular and many are -longitudinal, and these can only be differentiated macroscopicaIIy from typhoid ulcers by the absence of tubercles on the peritoneal surface. In most cases there is some attempt at healing and this may be shown by fibrosis and thickening either in the margins or at the base of the ulcer. rrhis process usually results in a protection of the base and to a large extent guards against the risk of perforation. In some cases the healing process proceeds almost to completion by fibrosis, and fibrous stricture of the bowel may result. As is shown in this series, however, this event is comparatively rare. It is more common to see evidence of healing and cicatrisation in some parts of ulcers which are showing signs of activity in other directions. \Vhen stenosis does occur, the strictures are usually multiple, although spastic strictures have been described. Stenosis is much commoner with pure intestinal tuberculosis, the reason being that in cases associated with active pulmonary disease the patient does not usually survive long enough for sufficient fibrosis to occur. Ulcers which are ragged and serpiginous are usuaIIy the result of a secondary infection. Tuberculosis has a tendency to spread by lymphatics, and· the regional glands are found to be commonly involved. It is stated that this occurs when the small intestine is affected, but is rare when the ulceration is confined to the colon. . Although these are the changes which are commonly noticed, it must be remembered that there are more diffuse changes found on microscopical examination. Not only may there be a diffuse hyperremia and round-celled infiltration of the whole wall of the intestine, but also there is a tendency for both of the nerve plexuses to be affected and it is thought that this disturbance of the nervous control of the bowel may be really responsible for the production of such symptoms as pain and diarrhcea. As has already been stated, it seemed probable that infection by contact and infection from the blood stream are both common causes of the condition. It is·difficult to explain why the blood-·stream infections should pick out the ileum andcrecum, yet the evidence in favour of blood-stream infections in a considerable proportion of the cases is such that it is impossible to ignore its existence. 'Vith regard to the ulceration which
TUDEHCLE
[May, HJ3G
accompanies active pulmonary tuberculosis, it is found that the activity of the ulceration is roughly proportional to the activity of the lung lesion as shown by the existence of recent cavitation and by large numbers of tubercle bacilli in the sputum. CLI~ICArJ FEATURES.
Symptoms.-Tuberculosis is notorious for the diversity of its symptoms and the intestinal type is no exception to this rule. 'l'here may be little or no abdominal discomfort in the presence of advanced disease and, conversely, there may be symptoms which point plainly to the intestinal tract incases in which at post-mortem there are no demonstrable lesions in any part of the bowel. l\Iost commonly in the early stages, there are slight digestive disturbances. A little discomfort after nwals, a feeling of fullness, occasional diarrhroa and constipation are very common and may be so slight that their significance is often overlooked. Commonly the patient feels unwell, as may be shown by an unexplained nervousness as to his condition, the weight shows a tendency to drop and there may be occasional slight pyrexia. A fairly characteristic feature of the complaint is a tendency to remissions. 'l'he more important and more definite symptoms must be considered separately. Pain is not by any means always present, nor is it an early symptom. It usually commences in the centre of the abdomen, but sooner or later radiates towards the right iliac fossa. Occasionally it is situated in" the epigastrium and it may have such a definite relation to meals that the presence of a gastric ulcer is suspected. It is usually most marked in the afternoon and may be accentuated by food. In a later stage the pain may be cramp-like or colicky. It is stated that a throbbing or burning sensation in the abdomen is associated with the presence of enlarged glands, and this may occur even when the mass has completely calcified. The reason for the pain is not clear. Severe ulceration may exist without any pain whatever and it is suggested hypermotilityand spasm are the usual causes. The pain is therefore seen to be associated more with muscle activity than with the"actual ulceration, and this in turn is thought to result from inflammatory involvement of the nerves in Meissner's plexus which is usually more involved than that of Auerbach. Diarrhroa, although it may be regarded as the classical symptom, is by no means the rule and there may even be marked constipation. "The onset of diarrhroa is often gradual and it commonly follows constipation. A frequent feature is the occurrence of remissions during which the bowel action may be practically normal. In many cases there is alternating diarrhroa and constipation. 'l'he cause of this diarrhroa may be either the increased peristaltic movements of the howel or diminished absorption of water and other products as a result of interference with blood" and lymph drainage. In some cases there lllay be very severe watery diarrhroa leading actually to clinical dehydration, the" intestinal sweats" of Graves. \Vhen ulceration occu~"s in the small intestine the prominent feature lllay be either diarrhcca or constipation, but with colitis
May, 1936]
INTESTINAL TUBERCULOSIS
345
diarrhooa is the rule. It is stated that constipation is associated ,.,.ith ulceration at the hepatic flexure of the colon. The number and situation of the ulcers, ho,vever, have no clear relation to the severity of the diarrhooa. This symptom may, in fact, be very marked when the only visible post-mortem change appears to be a simple catarrh of the mucous membrane. Tenesmus is only present in those cases in ,vhich the rectum is involved. Other abdominal symptoms of importance are nausea and vomiting. These are not very common but they may add to the difiiculty in diagnosis on occasion. They are usually associated with epigastric pain. rrhere may be considerable impairment of the appetite and distressing flatulence at times. . The temperature is very variable. In the majority of cases which prove fatal during the active stage of the disease there is a high. temperature which is usually remittent but, on occasions, the patient may be afebrile throughout the whole course of the disease. The most significant point in t.hose cases in which the condition complicates a known pulmonary tuberculosis is a temperature whieh remains raised while the pulmonary signs appear to indicate quiescence. In any case of phthisis in which there does not appear to be an adequate explanation for the temperature in the respiratory system a diagnosis of tuberculosis enteritis must be considered. . In rare cases, with very acute disease, there may be a typhoidal picture, and the differential diagnosis may depend upon serological reactions. Hremorrhage of any gross degree is rare. It may occur either from the small or from the large bowel and fatal cases have been described. As a rule, however, the intermittent passage of small quantities of blood is all that occurs. The weight falls very rapidly in most cases and an unexplained drop in weight has much the same diagnostic significance as an unexplained pyrexia. It must be remembered that many of the foregoing symptoms may be present without any demonstrable disease in the bowel. The symptoms are then thought to be toxic in origin and they undoubtedly result from a functional disturbance of the bowel mechanism. The existence of this type of symptom makes exact clinical diagnosis extremely difficult. Clinical examination is, as a rule, negative in character and beyond a localised "tenderness in those cases in which the peritoneum is involved there may be nothing "to be felt. Glandular masses and the hypertrophic type of disease cause lumps which are usually palpable. Rigidity is only present in those cases in which the inflammation is very acute, and is suggestive of perforation and local peritonitis. In most cases diagnosis must depend upon a consi~eration of the symptoms, a suspicion of the presence of tubercle, and the results of special investigations. INVESTIGATIONS.
Fmces.-The freces may appear normal on inspection, or loose stools may occur.. In very acute cases the freces may be watery and peculiarly
34G
TUllEHCLE
fretid. Visible blood llIay be present on occasion, and red blood-cells and pus lllay be detected under the microscope. ~'here is sometimes an excess of Cat in cases where the lymphatics are obstmcted. ,"Vhen there is extensive ulceration, occult blood is usualIy present. Examination of the stools Cor tubercle bacilli is frequently positive. "When there is known active pulmonary tuberculosis ,vith bacilIi in the sputum no significance can be attached'to this finding. In cases where there is no evidence of any pulmonary disease, the presence of tubercle bacilli in the stools is almost diagnostic of intestinal tuberculosis. Blood-examinations are not of much value. ~'here lllay be a severe secondary anromia, although this is not constant and there is usualIy a moderate "leucocytosis. A pernicious type of count has been recorded in cases of stricture of the smail bowel. 'rhe sedimentation rate is of no value in diagnosis and of little help in prognosis. EJldoscopic examination, by lUeans of the proctoscope or sigmoidoscope, mlty afford conclusive evidence when the lower part of the bowel is involved. It is of no value when the disease is located in the commoner sites. X-ray examination is not commonly practised in this country. " Its value has been stressed by IJawrason Brown and Samson in the United States and they emphasize the following points. "\Vhen a barium meal was given and followed at frequent intervals up to twelve hours they found localized areas of spasm in the region of the ulcers. "\Vhen the colon was involved they described a spastic filling defect which is usually permanent and suggests an organic alteration in the wall of the organ. Adhesions, as well as chronic tuberculous ulcers, also may produce a permanent alteration in the outline of the normal barium shadow. Intestinal huny is associated with active ulceration in the small bowel in some cases, but in atonic types of the disease and in early obstruction there may be marked retardation of the progress of "the meal. In cases where the mecum is involved, a barium enema may demonstrate constant spasm and the organ partially fills and empties; this condition of "intolerant crocum " appears to be fairly characteristic. ~'HEAT:'IENT.
'l'he prognosis IS usually regarded as being so bad that palliative measures are all that are considered as a rule. Attempts to achieve lUore permanent results have been made and must be considered if any improvement in our results is to" be obtained. Of course, the outlook is better when treatment is commenced in the early stages, and especially in those cases in which there is little or no pulmonary involvement. Cases in which miliary tuberculosis is present are invariably fatal and their treatment need not be considered. The first essential in treatment is prophylaxis. The patient should be instructed so far as possible not to swallow infected sputum. In addition it is desirable to give a mixture containing hydrochloric acid with meals and to give full doses of the main vitamins in all cases of active pulmonary tuberculosis. 'Vhen the presence of intestinal disease is established the first principle
l\Iay, H)3G]
INTESTINAL TUBBRCULOSIS
.347
of treatment is rest. The patient should be kept as still as possible and a cotton-wool pad over the abdomen is often of value in relieving discomfort. Exposure to chiIls must be carefuIly avoided. The diet must be carefully arranged. '1'he patient must avoid everything likely to cause intestinal movement, and cold drinks, milk, strong coffee, concentrated beef essences, fruit and salads should be avoided. In all cases it is desirable to avoid coarse, residue forming foods, and a low residue diet consisting of fruit juice, weak coffee, tea, cocoa, chocolate, white bread, jelly, eggs, and strained gruel should be advised. It is usually found that milk in large quantities is badly tolerated. As the clinical condition improves, thick soups, boiled fish, chicken, lean weat; potatoes, macaroni, purees and custards may be added to the diet, but all indigestible residue must be avoided. l\IacConkey advises cod-liver oil and orange juice or tomato juice in full doses and considers that the results of this treatment are beneficial. Drug treatment is not of great permanent value. ,Vhen dian-hooa is present bismuth or the old-fashioned astringents, such as kino or co to, a1:e often of value in checking this symptom. Calcium chloride given intravenously may be of considerable value not only in checking diarrhooa, but also in relieving pain which results from intestinal spasm. It is justifiable, in view of the good results of gold therapy in pulmonary tuberculosis, to give a course of sanocrysin, but the dosage should always be smaIl, starting \vith not more than 0·01 gram. In view of the good results obtained as a result of the induction of pneumoperitonenm in cases of tuberculous peritonitis with effusion, injections of oxygen have been employed in cases' of tubercular disease of the bowel and some success is claimed for this method. A much more promising method of treatment, however, is the use of heliotherapy. '1'he work of Hollier in Switzerland has emphasized the value of natural sunlight in most cases of non-pulmonary tuberculous disease. In most countries natural sunlight cannot be depended upon as a source of ray-therapy, and ultra-violet light (either fro111 mercury vapour or from carbon arc Jamps) has been extensively applied in the United States. The results are stated to be most encouraging, and it would appear that there is a field for the exploration of this line of treatment in this country. In cases where ultra-violet radiation has failed to effect improvement, some success has been claimed for X-ray therapy, but the reports are not convincing. Finally. in cases of localised abdominal disease, abdominal exploration may be undertaken. If the condition is sufficiently localised, excision may be practised, bilt if 'comparatively large area of bowel be involved in ulceration, then a short circuit may be performed. By this means rest of the affected part inay be achieved and healing may be encouraged, while obstructive symptoms may be overcome. It would appear from some of the published reports that the results of treatment in intestinal tuberculosis are more encouraging than have for a long time been supposed. Particularly is this the case with ultra-violet light therapy which might well be more extensively employed.
a