Definition:—A condition of sub-acute or chronic disease of the walls of the intestines, in which there is the characteristic deposit of tubercle, with the constitutional evidences.
The condition may be primary, from taking in the infective material with the food. (The digestive fluids in the stomach seem to protect that organ and render it immune, as it is seldom attacked.) Or it may be secondary to almost any other local tubercular infection. There being an hereditary constitutional weakness, a primary attack of the disease is more apt to occur in children up to the age of twelve years than in adults. With these, sooner or later, the peritoneum becomes involved, and the two conditions are coincident.
The disease occurs most commonly as a secondary infection in adults, following any other local infection, and especially following pulmonary infection from the swallowing of the saliva and sputum. Perhaps fifty-five per cent of the prolonged cases of pulmonary tuberculosis develop intestinal complications.
The bacilli, like the typhoid bacilli, find their first lodgment in Peyer's patches, in the solitary glands, and spread into the other structures, especially the lower part of the ileum, the cecum, the colon and rectum, and occasionally in the appendix, resulting in a diagnosis of chronic appendicitis.
Symptomatology:—In childhood a primary attack occurs after continued ill health, which may be attributed to heredity, or there may be malappropriation of food, with chronic stomach derangement and marasmus, and a general fault of development, or there may be some other underlying devitalizing cause.
One of my typical cases was that of a girl of eleven years, very fair, with light hair, light blue eyes and pale, waxy, transparent skin. The mother had died when the child was four years old, a few weeks after giving birth to another girl, which grew to adult age and enjoyed perfect health. When less than six years old the unfortunate girl was willfully taught to masturbate, and the habit became fixed, and after three or four years was almost constant, except when she was restrained by force. The intestinal disease showed itself perhaps eighteen months before death, with no evidence of previous infection elsewhere.
The evidences of impaired nutrition with emaciation are first seen. The condition is then soon found to be accompanied with irregular fever and occasional chilliness. At first there may be constipation, with colicky pains, but these are more apt to be an accompaniment of diarrhea, which is difficult of control. The movements are irregular in character, mixed with blood and mucus. Later, as the peritoneum becomes involved, there is diffused tenderness and a shrunken, contracted abdomen, unless there is free effusion, which is not common.
Occurring secondarily to an attack elsewhere, usually in adults, the symptoms arc insidious and difficult of diagnosis. The diarrhea, as well as the colicky pains and tenderness, arc thought to be due to the digestive disturbances. The fever, which has long existed, is not changed in character. Later, in cases where emaciation is pronounced, and where there is no extreme degree of peritoneal effusion, the nodular condition of the intestines may occasionally be felt through the intestinal walls. An unquestionable diagnosis can only be made by repeated microscopical examinations of the intestinal mucus obtained directly from the rectum.
Prognosis:—If nutrition can be sustained, these patients may live a number of years, and there is no doubt that a number of pronounced cases have recovered. The tendency is to increase of emaciation, and death from actual starvation, however, in adult cases of a secondary character, the primary affection will continue to advance and may result in death before the intestinal infection has progressed to any serious degree.
Treatment:—There are no specific measures that can be suggested in the treatment of this condition. The nutrition, must be maintained at its highest possible point. To accomplish this, all the measures which are suggested in pulmonary tuberculosis must be adopted. These are pure air, sunlight, proper exercise and concentrated and persistent nutrition. Even more attention must be paid to both gastric and intestinal digestion and assimilation than in other infections. In this disease intestinal peristalsis is apt to be very active, and often the presence of the least food in the stomach will induce almost immediate evacuation of the bowels. This must be restrained. The persistent use of Fowler's solution of arsenic in five-minim doses to an adult, after eating, will correct this condition, usually. Assistants to the digestion must be advised, even after the food has been selected with the utmost care. Hydrochloric acid is often indicated, and hydrastis and geranium should be administered persistently, adjusting the dosage, especially of the geranium, to the immediate conditions. Nux vomica and the bitter tonics, with persistent use of intestinal antiseptics, are all demanded.