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Dence of Compression. of Visceroptosis Conditions Arise Certain Contributing Factors Play a Part in Producing Dosis) of the Lumb

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Dence of Compression. of Visceroptosis Conditions Arise Certain Contributing Factors Play a Part in Producing Dosis) of the Lumb at different times, this is to be expected. It will only be In many cases of visceroptosis conditions arise after a very large number of cases are observed that we can within the abdomen that are an exact counterpart of state with any degree of accuracy the percentage of cases the experimentally induced constriction of Albrecht. due to the different of Our results from types organism. With the small intestine or in year to year, have been fairly consistent and the lying altogether chiefly however, the traction is made on the in results obtained in other general hospitals have agreed fairly pelvis, mesentery just the direction needed to cause a more or less closely with ours. complete occlusion The number of cases of meningitis observed by Dr. Litch- of the duodenum. field is extraordinary. I shall be interested to learn whether Certain contributing factors play a part in producing in any of these cases serum had been administered before the mesenteric ileus. The mesentery must not be too onset of the meningitis. The experiments of Dr. Wadsworth long, otherwise the small intestine is supported by the and those of Dr. Bull show that animals partially immunized pelvic floor and no drag ensues. Then again, the or inefficiently treated tend to develop local focal, rather duodenum is rendered much more liable to serious and that in the serious than general, infections, suggest very compression if there is any unusual prominence (lor- cases which are not efficiently treated, such focal complica¬ dosis) of the lumbar vertebrae This tions as empyema or meningitis may occur. This does not (Schnitzler4). increased lordosis was evident in Case 1 of our mean that empyema or other focal lesions occur more fre¬ very series. A dilated cecum in was quently in serum treated patients, but that patients who would displaced the pelvis otherwise die may be saved, to suffer from a focal lesion. To noted in five cases of chronic dilatation of the duo¬ determine this, however, will require many more observations denum reported by Bloodgood.5 "The distended than we have made up to the present. In collecting statistics cecum in the pelvis, the short mesentery of the ileum regarding the outcome of treated and untreated patients, I near the cecum, the demonstrable pull on the mesen¬ think we should always include all the patients dying, even tery, the dilated duodenum appeared to be the essen¬ die from complications not necessarily due to though they tial pathologic features." Jordan,6 who gives an pneumococcus infections, and this I have done. After all, such excellent of duodenal complications would not occur and the patients would not die roentgenographic description dilatation, looks on the mesenteric and had they not suffered from pneumonia. drag subsequent duodenojejunal kinking as one of the complications of ileac stasis. "The last coils of the ileum are nor¬ above the if there be marked DILATED DUODENUM mally placed pelvis ; any delay in the passage of the ileal contents into the WITH ESPECIAL REFERENCE TO CHRONIC DUODENAL cecum, these last coils of the ileum become overloaded OBSTRUCTION IN VISCEROPTOSIS and fall into the pelvis. In falling they drag on the DOUGLAS VANDERHOOF, A.M., M.D. mesentery," etc.7 Professor of Medical College of Virginia Our experience with chronic dilatation of the duo¬ Medicine, denum due RICHMOND to mesenteric obstruction embraces six cases. In the first the condition was The terminal of the duodenum behind patient recognized portion passes at necropsy ; in two instances the duodenal dilata¬ on the only the root of the mesentery and lies vertebral tion was demonstrated at and the column In because of his operation, diagnosis and aorta. the human being, in three cases was confirmed exami¬ erect this transverse of the duodenum is by Roentgen-ray posture, part nation. From the study of we are more or less con- these#patients compressed by the mesentery and its certain that we have overlooked other instances of tained superior mesenteric artery. In 1899, Albrecht1 chronic mesenteric ileus and that, in the out that this of the duodenum has, general, pointed segment clinical manifestations of duodenojejunal kinking are under normal conditions, not a round contour but a frequently misinterpreted. distinctly flattened circumference. Codman,2 a few years ago, also emphasized this fact and presented REPORT OF CASES casts of a number of duodenums showing definite evi- Case 1.—Clinical Summary: Jaundice at onset of illness dence of compression. five years ago, followed by aching pain in upper right abdo¬ This normal constriction of the duodenum may men; became nervous, hypersensitive and overreligious; fre¬ readily be increased by slight anatomic variations, or quent nausea and vomiting past four months; obstinate certain conditions, up to the of constipation; progressive loss of weight and strength; lordosis by pathologic point and no complete occlusion of the intestines. Albrecht not only visceroptosis; abdominal distention; acidosis; death; demonstrated this normal constriction of the duo- necropsy; dilated duodenum. Miss M. (5216), aged 20 years. Date: Oct. 17, 1914. Com¬ denum in the cadaver but showed that if a be finger plaint: Vomiting, weakness and pain in upper right abdomen. the the same introduced into duodenum and at time .History.—Patient had occasional attacks of tonsillitis, nb be made on gentle traction downward the mesentery, other acute infections ; her general health was good. In 1909 the constriction becomes more distinct and very evi¬ dent to the It is obvious that when 4. Schnitzler: Wien. klin. Rundschau, 1895, 9, 579, 593. examining finger. 5. Bloodgood, J. C.: Dilatation of the Duodenum in Relation to Sur- this of the reaches a gery of the Stomach and Colon, The Journal A. M. A., July 13, 1912, pressure mesentery degree great 117. more the muscular efforts p. enough to give resistance to 6. Jordan: Brit. Med. Jour., 1912, 1, 1225. of the duodenum than the closed pylorus, the condi¬ 7. Jordan's article is well illustrated with roentgenograms and and tracings in the case of a woman with a hugely dilated duodenum. He tion becomes of pathologic significance. Albrecht, also describes a vivid fluoroscopic picture, namely: "The duodenum afterward Connor,3 showed on the cadaver that trac¬ was half as long again and more than double the width of a normal duodenum. For seven or eight minutes the duodenum was observed tion on the mesentery in the direction of the axis of undergoing vigorous writhing contractions in a vain endeavor to force the obstruction in the duodenum its contents into the jejunum through the kink at the duodenojejunal pelvis may produce junction. After seven or eight minutes a very powerful contraction of which will be impervious to water under considerable the duodenum forced a large mass of bismuth emulsion through sud- denly into the jejunum, and the bismuth forthwith began to course pressure. rapidly through the coils of the small intestine. Fifteen hours after the bismuth meal the stomach and duodenum no longer contained Read before the Section on Practice of Medicine at the Sixty\x=req-\ any bismuth; the greater part of it was found to be in the lower coils Eighth Annual Session of the American Medical Association, New of the ileum in the pelvis. The cecum also occupied the pelvis. hours after the bismuth meal there was some bis- York, June, 1917. Twenty-seven still . 1. Albrecht: Virchows Arch. f. path. Anat., 156, 285. muth at the lower end of the ileum, and the most advanced portion 2. Codman: Boston Med. and Surg. Jour., 1908, 158, 503. had reached the sigmoid. Thus the sojourn of the bismuth in the small 3. Connor: Am. Jour. Med. Sc., 1907, 133, 345. intestine was more than three times the normal." Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/03/2015 the patient had jaundice for two weeks with nausea but no Necropsy (Dr. C. Willis).—This was performed two pain. She had a recurrence one month later with the same and one-half hours after death and was limited to the symptoms and duration. Made a complete recovery but a abdominal cavity. The peritoneum was everywhere smooth few months later developed a pain in the upper right abdo¬ and glistening. The liver, gallbladder and ducts were men. This continued but was never acute or severe, described normal. The pelvis, urinary bladder, appendix, kidneys and as an aching. Became very nervous and overreligious. In suprarenal glands were normal. The transverse colon and 1912 the patient discovered a lump in the right side of the most of the small intestines were in the pelvis. The for¬ abdomen (floating kidney?) and saw a surgeon who advised mer was deeply injected and somewhat distended with gas. against operation. Her nervousness and abdominal discom¬ The small intestine was collapsed. The lower portion of the fort increased. No history of any acute attacks of abdominal ileum contained some fluid. There were few small subserous pain. hemorrhages on the walls of the jejunum. Passing upward, In June, 1914, patient began to suffer with frequent nausea the lumen of the small intestine became smaller and smaller and vomiting. The vomitus was always sour and contained as the duodenum was approached. The duodenum just behind a great deal of bile. (Relation of pain and vomiting to meals the mesentery of the small intestine was sharply kinked. The not stated.) No hematemesis. Bowels have been obstinately cephalad portion of the duodenum was greatly dilated (diame¬ constipated. Progressive emaciation and weakness. No ter 3 to 4 inches) and filled with gas but its walls were not diarrhea or stomatitis. injected. The stomach was moderately dilated and contained Examination.—Physical examination was negative, except about a pint of dark fluid.
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