Georges Dieulafoy.

A text-book of medicine, Volume 1 online

. (page 97 of 129)
Online LibraryGeorges DieulafoyA text-book of medicine, Volume 1 → online text (page 97 of 129)
Font size
QR-code for this ebook


tubercular patients enteritis is a sign of evil augury. It often ushers in the
ccMjhectic period, leading to malnutrition, and hastening a fatal ending.

Hsemorrhage from the bowel is very rarely fatal, though in Chandeze's
case the patient had several attacks of haemorrhage, which were so profuse
that he succumbed in twelve hours. The post-mortem examination re-
vealed ulceration of the vessels. In Vallin's case intestinal haemorrhage
killed the patient in a few hours ; in Honot's case the intestinal haemorrhages
followed in quick succession, and the patient succumbed in two days.

In children tubercular enteritis is always associated with lesions in
the mesenteric glands (Parrot). This entero-mesenteric tuberculosis was
long known under the name of (abes mesenterica. It is characterized
by symptoms of enteritis, and also by distension of the abdomen, dilatation
of the veins of the abdominal wall, and effusion into the peritoneum.

Perforation of the bowel with peritonitis is exceedingly rare. It would
seem at first sight that tubercular ulcerations of the gut might cause
perforation, but thia is not the case.

In chronic ulcerative tuberculosis Koch's bacilli may pass into the
tributaries of the portal vein and reach the liver, where they cause inter-
stitial hepatitis. The lesion is periportal, and is accompanied by secondary
cirrhosis and perilobular fatty infiltration.

Diagnosis. — In some cases of miliary tuberculosis, the intestinal troubles
and the general symptoms resemble the clinical picture of enteric fever. In
chronic tubercular enteritis the diagnosis is the more difficult, in that the
case does not always look like one of tuberculosis. For months and
years phases of improvement occur, and the intestinal troubles are ascribed
to gastro-intestinal dyspepsia or to the arthritic diathesis. We must, how-
ever, be always on our guard. Cases of interminable diarrhoea or enteritis
which seem to recover at Plombieres or elsewhere, and then relapse, are
most often the result of tuberculosis. In exceptional cases the tubercle
bacillus has been found in the stools.

Tubercular enteritis is often rebellious to treatment. Subnitrate of
bismuth in large doses, lime-water with morphia in very small doses, albumin-



Digitized by



Google



^92 TEXT-BOOK OF MEDICINE

water, and nitrate of silver in pilk, are the means usually employed. A diet
in which raw meat is the chief ingredient is generally associated with these
medicines to advantage. Lactic acid (Hayem) and powdered talc (1 ounce
a day) (Debove) have been recommended. The cure at Plombieres is of
great service.



VII. HYPERTROPHIC TUBERCULOMA OF THE CiECUM—
DIAGNOSIS OF THE TUMOURS OF THE RIGHT ILIAC FOSSA

This variety of tuberculosis commences in the caecum or the ileo-caecal angle, and
runs a chronic course. It is often primary ; it produces tumours which simulate
lymphadenoma, and is often curable by operation.

This malady was described by Duguet in 1869. Surgeons have called attention to
it (Terrier), and in the earliest operations they thought they were dealing with lympho-
sarcomata of the csecum (Bassini, 1887 ; Bouilly, 1889). I may quote the works of
BiUroth (1891), Hartmann, Pilliet and Brooa (1891), of Roux (1892), and the theses
of Le Bayon (1892) and Benoit (1893).

I have collected a great number of cases in my clinical lectures,* and I have proposed
the name of hypertrophic tuberculoma of the cacum for this disease.

Hartmann and Klliet had described it under the name of " chronic tubercular
typhlitis and csecal tuberculosis." This name has the advantage of assigning the chief
importance to the lesion of the csBCum. Other authors have described it under the name
of " chronic ileo-caecal tuberculosis," but this name is not exact, because it induces a
belief that the lesion commences in the ileum, and then spreads to the caecum, which
is by no means always the case. Sometimes, indeed, the walls of the ileum are hyper-
trophied, and this fact might at first sight induce a belief in a tubercular lesion of this
portion of the gut ; but closer inspection shows that it is only a compensating hyper-
trophy caused by the stenosis of Bauhin's valve or of the caecal cavity, and that this
hypertrophy must not be confounded with a tubercular lesion. In short, hjrpertrophic
tuberculosis does not commence, as a rule, in the ileum, but in the caecum, close to the
ileo-caecal valve (Hartmann, Broca). The lesions are most pronounced, and the caecal
walls attain their greatest thickness at this point, so that the term hypertrophic tuber,
euloma of the cacum seems to me to apply in the majority of cases.

The tuberculoma may remain limited to the caecum without invading the colon,
as in one of my cases. In most of the published cases, however, the caecal tuberculoma
spreads along the intestine, and finally reaches the ascending or even the transverse
colon. In one of my patients, operated on by Legueu, the lesion b^an in the caecum,
invaded the ascending colon and part of the transverse colon. In Broca's case the
lesion affected the colon, the mucous membrane being polypoid for about 3 inches.
In Marion's case the lesion started in the caecum, and spread into the ascending and
transverse colons. In Bouilly*s case the caecal lesion had encroached on the ascending
colon. In Roux's case the lesion started in the caecum, and invaded the whole of the
ascending and transverse colons. Hypertrophic tuberculoma does not, then, remain
confined to the caecum in the great majority of cases ; it finally invades the colon. This
distinction is important, as we may think that the operation should be limited to the
caecum, and then find a lesion which has invaded the ascending and the transverse
colons, so that it is necessary to remove 10 or 12 inches of bowel.

♦ Dieulafoy, " Tuberculome Hypertrophique du Caecum ; Diagnostic dee Tumeurs de
la Fosse lliaque Droite " (Clinique Mcdicale de VHCtelDieu, 1903, H"*" et 15"*^ le9ons).



Digitized by



Google



DISEASES OF THE INTESTINE 793

Pathological Anatomy. — Let us suppose a case in which the surgeon
has just performed the operation. It is often tedious because the
tumour is adherent to the organs in the iliac fossa, to the peritoneum, or to
the anterior abdominal wall ; chains of glands start from the tumour and
reach towards the spine or spread out into the iliac fossa.

The tumour at first sight might be taken for a lymphosarcoma or cancer,
on account of its external and also of its internal appearance. When we
handled the tumour removed by Bouilly, we thought it a cancer of the
caecum. At the fij^t microscopic examination Pilliet considered the mass
to be a lymphosarcoma, and it was only later, on a second examination, that
he recognized the case as hypertrophic tuberculoma. In a case reported by
Chavannaz and Carriere they thought of cancer of the caecum, even when
they saw the tumour. The tubercular nature of the tumour was shown
later on microscopic examination. Dr. Antipas recently sent me the caecum
of a patient whom he had cured by operation. According to his idea, it
was a case of hypertrophic tuberculoma. We thought that it was a
lymphosarcoma, but the microscopic examination made by Nattan-Larrier
showed that it was really a tuberculoma with bacilli. It is probable that
many cases formerly called cancer of the caecum were really cases of hyper-
trophic tuberculoma.

The tumour is formed by the caecum, which is much thickened, nodular,
surrounded by caseous glands, and embedded in a thick mass of fibro-adipose
tissue. The condition is, therefore, a true fibro-adipose perityphUtis, quite
comparable to the fibro-adipose perinephritis which accompanies a tuber-
cular kidney. This envelope was enormous in my specimens. It has
been found in several cases, and Hartmann and Pilliet have given an
excellent description of it in their work published in 1891.

The walls of the caecum are sometimes enormous. They are lardaceous
or fibroid, and creak under the scalpel. In my patients they were about
1 inch in thickness, while their thickness was half an inch in Marion's case
and 2 inches in Gussenbauer's case. This hypertrophy is in part due to
the fibroid tubercular change in Ihe walls.

When the caecum is opened, the internal surface projects, in the form
of pillars and columns, as in one of my patients. Vegetations of a poly-
poid or papillomatous appearance may be seen, and resemble the tuber-
cular vegetations found in the larynx. Ulcers are seen in places. The
ileo-caecal valve is sometimes ulcerated and destroyed, or at other times
indurated and rigid, with a much constricted orifice. These lesions may
cause stenosis of the intestine at the valve and in the cavity of the caecum
itself. This stenosis induces constipation and intestinal obstruction. In
severe ileo-caecal stenosis the last portion of the ileum is much dilated,
and the ascending colon is contracted.



Digitized by



Google



794 TEXT-BOOK OF MEDICINE

Microscopic examination shows that the thickening is due to a con-
siderable infiltration of embryonic cells, which resembles sarcomatous
tissue. This infiltration replaces the tunica mucosa, and invades the
tunica muscularis, pushing aside the fibres. Tubercular granulations and
large tubercles may be found in the cellular layer, but this process does not
end in caseation, but in fibroid change, which makes the wall rigid and
thick. Koch's bacilli were very numerous in the preparations from the
caecum of one of my patients.

Tuberculosis of the caecum always produces enlargement of the glands.
They are more or less numerous and enlarged, and indurated or caseous.
They are usually found in the ileo-caecal angle, but some may be met with
in the mesentery, near the pancreas, in the supraclavicular region, and
in the groin.

Ileo-Csecal Appendix. — In these cases the walls of the appendix are
almost always hypertrophied, and show tubercles, and yet the patient has
not appendicitis in the clinical sense of the word. He has tubercular lesions
in the appendix, but they do not give rise to the closed cavity, and conse-
quently to the toxi-infectious symptoms which alone deserve the name of
appendicitis.

I do not say that such a result is impossible, but I can find no mention of
purulent peritonitis, remote abscesses, subphrenic empyema, purulent infec-
tion of the liver, putrid pleurisy, or toxic lesions in the kidneys, liver, and
stomach, which are the appanage of appendicitis. An individual may,
therefore, have tubercular lesions in the caecum, and the appendix may
be involved in the tubercular mass, but the terrible effects of appendicitis
do not occur.

What is true of hypertrophic tuberculoma is equally true of ulcerative
ileo-caecal tuberculosis. I remember a phthisical patient who suffered
from ulcerative tuberculosis of the intestine. The appendix was much
affected by tubercular lesions, but they were parietal, and had not caused
the formation of a closed cavity. Furthermore, the patient had never had
any symptoms of appendicitis, and tte* histological and bacteriological
examinations confirmed the absence of any toxi-infectious focus in the
appendix. In other words, tuberculosis of the appendix and appendicitis
are two very different things, and it would be wrong to include them in one
classification. Tuberculosis of the walls of the appendix is fairly common,
whilst tubercular appendicitis is exceedingly rare. This is also the opinion
of LetuUe, whose authority in this matter is great. As a general rule, the
lesions of the appendix (tuberculosis, actinomycosis, cancer) which remain
limited to the walls of the appendix do not cause appendicitis. These
lesions may also be present in the tissues around the appendix, but they are
incapable of poisoning the system, like the focus of appendicitis, which is



Digitized by



Google



DISEASES OF THE INTESTINE 795

closed, and contains organisms. It is certain that patients suffering from
hypertrophic tuberculoma of the caecum do not SUCCumb to appendicitis,
and the prognosis is at least free from this complication.

Clinical Cases. — Two years ago I admitt€d into the Hotel-Dieu a woman, of thirty-
nine years of age, who had suffered for eighteen months from chronic diarrhoea and
acute abdominal pains, especially in the right iliac region. From the commencement
of the disease she had passed six or eight stools daily. The diarrhoea was not always
preceded by colic, and had no special characters, as blood, mucus, and membranes
were not present.

The pains were exceedingly acute and continuous or paroxysmal, but we noticed
no special time of onset, which might have helped us to localize the intestinal lesion.
They were most marked in the right iliac fossa.

She did not look ill, in spite of the duration of the disease. Nevertheless, she had
lost flesh for the past two months, and the diarrhoea had been incessant. Treatment
had given no reliof.

What disease had caused so much pain and diarrhoea for eighteen months ? There
was no fever ; the uterus and its adnexa were normal. Examination of the abdomen
disclosed a tumour of the size and shape of a pear in the right Hiac fossa. The tumour,
which was painful on pressure, was fairly mobile and indurated, but not nodular.
Its lower portion was wider, and reached nearly to Poupart's ligament, and its upper
more narrow portion reached up in the direction of the ascending colon. Internally
it did not reach the middle line. These signs and this localization being given, we could
think only of the csecimi. It was still necessary to know its nature, because many
tumours occur in the right iliac fossa.

I diagnosed hypertrophic tuberculoma of the caecum, and not cancer, because the
wasting was only of two months' duration. Furthermore, the sero -diagnosis of
tuberculosis was positive, and confirmed the clinical diagnosis. The lungs were
sound, and the case was, therefore, primary tuberculoma of the C89cum. Under these
conditions, operation seemed to me to be imperative, and I requested Legueu to
perform it.

An incision 6 inches long was made at the outer border of the rectus muscle. When
the peritoneum was opened, the indurated portion of the intestine was exposed. Ex-
amination showed that the chief trouble was ii> the caecum, which formed a large tumour.
Legueu also found that the induration of the intestinal wall extended as far as the
hepatic flexure. The ileum was healthy.

The diseased intestine was removed, and the two ends of healthy bowel (ileum and
transverse colon) were joined by end-to-end anastomosis.

Some enlarged glands were removed from the mesentery. A catgut suture was
applied to the free edge of the mesentery, so as to unite the tAvo layers. The operation
was concluded by the suture of the abdominal wall and the insertion of a single diainage-
tube.

The patient had a motion on the third day. Wo commenced to feed her with milk
and broth. The drainage-tube was removed, and from the eighth day onwards the
progress was rapid.

Five weeks after the operation she was fat and well. Some 10 inches of intestine
were resected, thus removing a tubercular lesion of eighteen months* duration, which
would have had a fatal ending. At the present time her appetite is excellent, and
her digestion is normal. The abdominal pain and the diarrhoea have completely dis-
appeared.

Eight months later she came back to see us at the Hotel-Dieu. She had gained
about 20 pounds in weight, and had not felt the least malaise since the operation — a
proof that the lesion had been taken away in tolo. Although the caecum, iloo-caecal



Digitized by



Google



796 TEXT-BOOK OF MEDICINE

valve, ascending colon, and a portion of the transverse colon were removed, her digeg
tion was as regular as with a normal intestine.

Immediately after the operation we examined the specimen. The portion resected
by Legueu comprised the end of the ileum, the cseoum, the ascending colon, the hepatic
flexure, and a part of the transverse celon — ^in all, about 10 inches of gut. The following
figure shows the intestinal lesion in detail.

The ileum was quite normal.

The caecum formed a large tumour, the size of which has been increased by an
adherent fibro -fatty sheath (/). Its nodular siurface gave at first sight the impression
of a sarcoma. Caseous glands were found at various points.

After opening the specimen we found the following details :

The walls of the osdcum were hard and fibroid, being 1 inch thick at the bottom (e),
and I inch a little higher. The walls of the ascending colon were } inch thick, and those
of the hepatic flexure (b) were } inch. The lesion began at the bottom of the csecum,
and became less marked as it extended towards the colon. The csecal cavity was con-
stricted by the thickening of the walls. Concentric hypertrophy was present.



Fig. 64,

r

The internal surface of the caecum was irregularly corrugated. The ileo-caecfrl valve
(d) was indurated, open, and constricted. Two superficial ulcers were found — one (c)
in the ascending colon, and the other in the transverse colon. The appendix was
slightly indurated and hypertrophied.

The histological examination by Nattan-Larrier showed the following details :

The hypertrophy of the walls of the caecum was confined principally to the sub-
peritoneal cellulo -fibrous layer and to the submucous layer, where the tubercular
lesions attained their maximum.

The epithelium of the surface was preserved everywhere without a trace of ulcera-
tion. The glands of the mucous membrane were very much hypertrophied. In the
submucous layer marked infiltration of leucocytes and a considerable number of small
isolated or agglomerated tubercles were present. The muscular layer was separated by
abundant oedema, and embryonic infiltration was found at certain points. The serous
layer was very rich in adipose tissue, and patches of very dense fibrous tissue and some
small tubercles were also found. Films on slides revealed the presence of Koch's



Digitized by



Google



DISEASES OF THE INTESTINE 797

bacilli. The histological examination of the appendix showed non -tubercular hyper-
trophy of the walls, with obliteration of the canal throughout its whole length.

Another patient suffered from continual diarrhoea, and could not take food. He
had lost 50 pounds in weight in three years. In the right iliac fossa he had a tumour
which was easily felt, because the walls of the abdomen were very thin. Examination
of the region did not cause pain. The tumour was of ligneous consistency, and as big
as a large orange. It seemed to be adherent to the pelvis. It was 2 inches from the
linea alba, and 3 inches from the false ribs. Below, it did not reach Poupart's ligament.
The inguinal glands were hard, but not painful.

The tumour was evidently in the csecum, but how were we to know whether it was
cancerous or tubercular ? Induration of the tumour, glands in the groin, loss of flesh,
and cachexia were not sufficient to establish the differential diagnosis. The course of
the disease, however, was important. The patient had been ill for three years. At
this period an abundant bloody diarrhoea came on, and had never disappeared.
It came on immediately after the ingestion of food. Diarrhoea, abdominal pains,
anorexia, loss of flesh, and cachexia might be present in tuberculosis or in cancer of
the csecum. I nevertheless put aside the idea of cancer, on account of the long duration
of the disease. Besides, we had another argument in favour of tuberculosis — the patient
was suffering from pulmonary tuberculosis. The lung trouble was not the primary
disease, because the patient had been examined several times at the Hot^sl-Dieu, and
the lungs had always been found healthy. Two years and a half before he was treated
for intestinal troubles, but we found nothing the matter with his lungs. As the disease
became worse, he returned for advice a year later, and we again found intestinal symp-
toms, but no indication of phthisis. I therefore diagnosed hypertrophic tuberculoma
of the csBCum, with secondary disease in the lungs.

If this man had come to us earlier, before the onset of the lung trouble and of the
cachexia, I should not have hesitated as to operation. In his actual condition there
could be no thought of surgical Intervention. We tried in vain to feed the patient up,
but he succumbed six weeks after admission.

The results of the post-mortem examination were as follows : It was a case of hyper-
trophic tuberculoma of the caecum. There was a nodular tumour of the size of an
orange, which at first sight simulated a lymphosarcoma. The caecal tumour was en-
larged by a fibro-fatty covering. When this envelope was removed, the walls of thi
caecum {b) were greatly hypertrophied, fibroid, and lardaceous, as will be seen from
Fig. 55. The lesion was absolutely confined to the caecum. The ileum (d) and the
colon (a) were not affected. The delimitation of the lesion was as clear internally as
externally. A large ulcer (c) had destroyed the valve, and occupied the bottom of the
caecal cavity. Elsewhere the internal surface of the caecum was closely set with folds,
forming bridles, pillars, and columns. Glands were not numerous. The appendix,
though thickened and embedded in the fatty tissue around the caecum, had preserved
its normal calibre. In the histological preparations Koch's bacilli were found in
abundance.

Bouilly's case (the first case operated on in France) : A woman had been suffering
from gastro-intestinal troubles for five years. An immovable painful tumour of the
size of an orange was fou^d in the right iliac fossa, and was supposed to be an ileo -caecal
cancer. The tumour was removed. On examining the specimen, thickening of the
walls was found ; the ileo -caecal valve was unrecognizable, and the mucous membrane
of the caecum was covered with vegetations, which projected into the cavity. The case
was, therefore, a tuberculoma. The appendix was large, but the canal was patent.
Glands were present at the junction of the ileum and of the caecum. The patient was
in good health four years after this operation.

One of Billroth's cases refers to a child of ten years of age who had suffered from
intestinal troubles for two years. A tumour of the size of an apple, which was tendei



Digitized by



Google



798 TEXT-BOOK OF MEDICINE

on pressure, mobile in all directions, and of a ligneous consistency, was felt in the cssca\
region. In order to clear up the diagnosis, an injection of tuberculin was given, and
caused a reaction of 104® F. The case, therefore, was held to be tubercular. An
operation was performed. The tumour was 4 inches in length ; the ileo-osecal ^'alve
was much constricted ; the mucous membrane of the csecum was covered with polypoid
vegetations, surrounded by a callous zone. Microscopic examination showed an
infiltration of small cells, grouped in tubercles and giant cells. The operation was
followed by recovery.

Description. — The onset is generally slow and insidious. The patient
complains of abdominal pains, with alternate diarrhcea and constipation.
The pains, which are at times very sharp, may affect the form of coUc, and
be most severe in the right iliac fossa. The diarrhoea is sometimes inter-
mittent, or at other times as obstinate as in ordinary tubercular enteritis.
Blood is rarely present, contrary to what is noticed in ordinary tubercu-
losis of the intestine. During this first period the patient loses but little



FiQ. 56.

The stationary stage, during which the lesions become definite, varies
from a few months to several years. During this period the symptoms are
almost invariable, and comprise intestinal troubles, pains predominating
in the right iliac fossa, diarrhoea, constipation, vomiting, and loss of flesh.
The examination should be preceded by an aperient. Exploration of the
abdomen reveals hypersesthesia in the right iliac fossa, where an induration
or a tumour, varying in size from a nut to an orange, is found. The indura-
tion sometimes appears diffuse, uneven, and nodular ; at other times we
find a tumour fairiy circumscribed, mobile in every direction or only in a
transverse direction, or immobile, on account of adhesions in the iliac fossa
and to the abdominal wall. One or more fistulous tracks may open on the
skin of the iliac region. What does the general examination of the patient
teach us ? In a woman vaginal touch reveals the integrity of the pelvic
organs. The lungs are generally healthy, and pulmonary tuberculosis has



Digitized by



Google



DISEASES OF THE INTESTINE 799



Online LibraryGeorges DieulafoyA text-book of medicine, Volume 1 → online text (page 97 of 129)