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 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 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 . 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 . 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 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 ; 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, 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 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 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, , 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 . Bowels have been obstinately cephalad portion of the duodenum was greatly dilated (diame¬ constipated. Progressive and weakness. No ter 3 to 4 inches) and filled with gas but its walls were not or stomatitis. injected. The stomach was moderately dilated and contained Examination.—Physical examination was negative, except about a pint of dark fluid. The pylorus was patent. as follows : Cheeks were flushed ; tongue red and bald ; abdo¬ Conclusion : "The dilatation of the duodenum in this case men retracted ; lordosis to such an, extent that lumbar spine may be explained by two marked anatomic changes : First, does not rest on the bed ; both kidneys easily palpable ; moder¬ the extreme lordosis ; and second, the marked visceroptosis ate diffuse abdominal tenderness ; abdominal walls soft. which caused the mesentery to partially occlude the last por¬ Neurologic examination negative except as follows : Patient tion of the duodenum as it crossed the vertebral column." not appeared apathetic and depressed; knee jerks were Case 2.—Clinical Summary : Abdominal pain of five years' obtained. duration with suggestive ulcer syndrome; visceroptosis; pul¬ Roentgen-ray plates of chest were negative for active monary tuberculosis; operation showed chronic mesenteric tuberculosis. (The patient was too ill to undertake roentgen- ileus with dilated duodenum. ographic examination of gastro-intestinal tract). Mrs. R. (6156),.aged 37 years. Date: Nov. 1, 1915. Com¬ Blood : White blood corpuscles 6,900. Hemoglobin 70 plaint : Abdominal pain. 55 cent. Small mononu- per cent. Polymorphonuclears per History.—The past history has no special bearing on the clears 35 per cent. Large mononuclears and transitionals 8 present complaint. Average weight, 115 pounds. Present per cent. Eosinophils 2 per cent. Negative for malaria. weight, 97Vz pounds. Morphologically negative. The patient had vague digestive disturbance some years Urine (catheterized) : amber, acid, 1.020, albumin distinct ago with vomiting and abdominal pain with subsequent trace, sugar 0, indican slightly increased, acetone present, recovery. Had four attacks of acute abdominal pain, the diacetic acid present. Microscopically negative. first one seven years ago, last one two years ago. Dates the Gastric Analysis : Ewald test breakfast, removed in forty- onset of her present illness five years ago when she began to five minutes, 200 c.c. expressed. Gross appearance : greenish suffer with pain similar to toothache in the epigastrium. It fluid, finely divided bread particles, no visible blood, no occurs every day and is more pronounced for a week or ten excess of mucus, no evidence of stasis. Free hydrochloric days preceding the menstrual periods. The pain bears a def¬ acid 13, total acidity 24. inite relation to meals, occurring three to four hours after Course.—During the first week in hospital, temperature eating and is always relieved by eating. It is especially trou¬ ranged from 98.2 to 99.4 F., pulse 70 to 100; remaining six blesome about bedtime. The pain is located high in the epigas¬ days temperature S8.2 to 101 F., pulse 116 to 134. Almost trium and radiates up into the chest and through to the back. constant nausea, frequent hiccups, occasional vomiting. There is some flatulence but no vomiting. Patient has fre¬ Repeated stomach washings brought back greenish-brown quent dull , sleeps very poorly and is nervous. fluid. On one occasion gastric lavage returned some castor Examination.—Patient is an undernourished, sallow woman. oil given twenty hours previously. Solution of dextrose and Has signs of pulmonary tuberculosis in both upper lobes, bicarbonate of soda by bowel retained. Obstinate constipa¬ more marked on the right. The abdomen shows signs of tion, but stools were secured daily by enema and purgatives. counterirritation in epigastrium. A general rigidity makes Mind was perfectly clear. No abdominal distention. Marked palpation unsatisfactory. Has rather marked tenderness in prostration. the epigastrium and beneath the right costal border where a Oct. 30, 1914. Patient died at 8:15 p. m. In the past forty- typical gallbladder block is elicited. Blood, urine and gastric eight hours has not vomited but has regurgitated small analysis are normal. The gastric contents contained much amounts of slightly colored fluid on three or four occasions. bile, no stasis. Clinical diagnosis lay between peptic ulcer and Yesterday she took and retained a little nourishment by chronic . mouth, and last night retained 8 ounces of magnesium citrate. Operation (Dr. A. M. Willis).—The gallbladder and stom¬ Bowels moved twice today. Kidneys have been acting quite ach were negative. Appendix was slightly thickened. The freely until today, when secretion became scanty. Urine has duodenum was greatly dilated down to a point where it passed continued to show large amounts of acetone and diacetic acid. behind the mesentery. General enteroptosis. Appendix was The abdomen has been uniformly retracted until today, when removed and an attempt made to free the obstruction about rather marked distention appeared. The past three days the the duodenum by widening the slit in the me^;ntery. patient complained of being unable to see or hear well. The Seven months later patient had developed well-marked cheeks have remained flushed and there has been no jaundice. laryngeal tuberculosis but her abdominal symptoms were Several days ago the mouth became red and inflamed and improved. today she has had difficulty in swallowing. Case 3.—Clinical Summary: Recurring spells of The following opinions as to the nature of patient's illness for fifteen years with régurgitation of food; suggestive gall¬ were entertained by bladder syndrome ; pulmonary tuberculosis; no definite viscer¬ (1) Family physician : Chronic cholecystitis. optosis; Roentgen-ray examination showed dilated duodenum (2) Consulting neurologist: "If you can exclude gall¬ with stasis. bladder disease, I think her emaciation and vomiting can be Mr. W. (6284), aged 43 years. Date: Jan. 4, 1916. Com¬ accounted for by hysteria." plaint : Stomach trouble. (3) Consulting surgeon: No obstruction, no surgical History.—Patient had typhoid twenty-five years ago. Used lesion ; some underlying toxemia, possibly pellagra. whisky freely until two years ago. There is no history of (4) Medical attendant : Visceroptosis, persistent vomiting venereal disease. Average weight, 150 pounds. Present of undetermined origin, starvation, acidosis. weight, 124 pounds.

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/03/2015 The present illness began fifteen years ago with recurring Mrs. M. (7435), aged 41 years. Date: Feb. 17, 1917. Com¬ spells of indigestion, now becoming more frequent. He has plaint : Vomiting, and pain in the right side of the abdomen. become extremely nervous and apprehensive. There is no History.—The past history is unimportant. Average actual vomiting but the chief complaint is régurgitation of weight, 93 to 94 pounds. Present weight, 85 pounds. food twenty to thirty minutes after eating. There is no dif¬ The present illness began five years ago with soreness in ficulty in swallowing. A good deal of sour stomach and flat¬ the right side of the abdomen just below the costal border, ulence. There is a history of two short attacks of severe headache, nausea and vomiting. On operation in another city cramp colic in the past year requiring morphin. In general, four years ago the gallbladder was drained ; no stones were his indigestion is not characterized by pain. He says he spits found. No relief was obtained and two months later she up his food because it induces fulness in the stomach with was much worse. The same symptoms have continued. pressure about the heart which makes him very nervous. Vomiting generally occurs two to four hours after eating. Bowels are always constipated. Has no jaundice. The vomitus is very sour and almost always contains much Examination.—Patient is sallow and poorly nourished. The bile. No relief is obtained by food or soda. There are chest shows signs of fairly extensive tuberculosis in the right flatulence and distention. There have been no attacks of acute upper and middle lobe with some involvement at the left apex. abdominal pain. The bowels are slightly constipated. The The abdomen is entirely negative except for rather pro¬ stools are occasionally light colored. nounced general rigidity. There is no localized tenderness. Examination.—This proved negative except for evidence There are no masses and no free fluid. The blood and urine of visceroptosis and considerable emaciation, and moderate aœ negative. Gastric analysis by the fractional method diffuse abdominal tenderness, possibly more marked in the showed moderate hyperacidity. upper right quadriint. Gastric analysis was normal. Blood and Roentgenograms of the chest confirmed the physical find¬ urine were negative. The Wassermann test was negative. ings. Fluoroscopic examination and plates of the abdomen Operation (Dr. A. M. Willis).—Operation disclosed adhe¬ after an opaque meal showed moderate pylorospasm and con¬ sions about the gallbladder and a greatly dilated duodenum siderable six hour residue. The duodenal cap was very large to a point where it went behind the mesentery ; the adhesions and dilated with considerable lagging of the meal in the were freed and the gallbladder removed. An attempt was second and third portions of the duodenum. No constant made to relieve the duodenal obstruction by widening the slit deformity to indicate ulcer in either stomach or duodenum. in the mesentery. The patient was advised to follow the (It is barely possible that the duodenal constriction was operation with a prolonged rest cure in order to increase her caused by a tuberculous .) weight. She made an uneventful convalescence from her No operation. Patient left the hospital unimproved. operation and left the hospital much improved. Case 4.—Clinical Summary: Neurotic girl complaining of Case 6.—Clinical Summary: Nausea and vomiting for four vomiting, abdominal pain and distention; previous appendec¬ years; habitus enteroptoticus; previous appendectomy; Roent¬ tomy with no amelioration of symptoms; Roentgen-ray exam¬ gen-ray examination revealed pronounced visceroptosis with ination showed and marked dilatation of the dilatation of the duodenum and stomach. duodenum. No Heal stasis. Miss R. (7600), aged 20 years. Date: April 4, 1917. Com¬ Miss P. (7386), aged 15 years. Date: Jan. 25, 1917. Com¬ plaint : Nausea and vomiting. and plaint : Pain in the right side of the abdomen, vomiting History.—Unimportant. Average weight, 85 pounds. Pres¬ nervousness. ent weight, 82 lbs. About 4 years ago the patient began to History.—The past history has no direct hearing on her suffer with nausea, headache, backache and weakness. She well present condition except to note that she had never been was treated for "chlorosis" for two years. She was oper¬ 106 or strong. Average weight, 113 pounds. Present weight, ated on in September, 1916, for acute . Her pounds. appetite is poor. She has nausea and vomiting nearly The present illness began about three years ago when the every day. This generally occurs immediately after eating patient complained of abdominal distention with nausea, vom¬ and the vomitus consists of food and bile. She has heart¬ iting and pain throughout the right side. She was operated burn occasionally and gnawing but no abdominal pain except on two years ago for an attack of supposed acute appendicitis at the time of her attack of appendicitis. Her bowels are showed but her family physician states that the appendix very regular. She has frequent headache, but no fever. This was followed no little evidence of being diseased. by Complete physical examination was negative. The blood distention and occur in improvement. Her pain, vomiting and urine were normal. The Wassermann test was negative. She has almost constant attacks lasting one to three weeks. Gastric analysis by the fractional method showed a normal as she has nausea coming on as soon she eats. Occasionally secretion. and The bowels are regular. sour stomach belching. Roentgen-ray examination of the chest showed that it was considerable ver¬ The patient has had some headache and extremely elongated in comparison with its horizontal diame¬ been nervous and at times laughs tigo. She has always very ter. Heart was small and vertical. There was no evidence and cries in an uncontrollable way. She has had a good many of tuberculosis. fainting attacks. Roentgen-ray examination of gastro-intestinal tract showed Examination.—This revealed tonsils and several enlarged dilatation and ptosis of stomach, the greater curvature reach¬ teeth. The abdomen was very difficult to examine as decayed ing into the pelvis. There was no evidence of ulcer; no skin to be hyperesthetic and the the appeared everywhere pylorospasm, but distinct six hour residue ; marked dilatation could not be made to relax. The physical condition patient of duodenum ; whole colon was very low. Also ptosis of was otherwise negative. liver and spleen. The blood and urine were negative. The Wassermann test This patient was placed on medical treatment in the hos¬ was Gastric fractional method showed negative. analysis by and her ceased After three weeks moderate pital vomiting promptly. subacidity. she returned to her home in the to continue her examination was with no evidence of country Neurologic negative, treatment. true epilepsy. Roentgen-ray examination of gastro-intestinal tract showed COMMENT some gastroptosis with slight dilatation of the stomach and As to the incidence of duodenal obstruction from all very marked dilatation of the duodenum. No ileal stasis ; causes, Anders,8 writing in 1912, was able to collect colon peristalsis was good. 262 cases. In over one half of this number the Medical treatment was outlined and patient returned to her stenosis was the result of duodenal ulcer. In twenty- a of the state. home in distant part nine cases, or 11 per cent., the constriction was attrib¬ Case 5.—Clinical Summary: Vomiting and abdominal pain uted to the root of the In without vis- compression by mesentery. for five years; previous cholecystostomy relief; Anders' statistical table it is seen that ceroptosis; operation; chronic mesenteric ileus with dilated examining duodenum. Anders: Am. Jour. Med. Sc., 1912, 144, 360.

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/03/2015 twenty-seven of these twenty-nine cases were reported also refers to the report of Stavely,10 of Washing¬ by one author as having been found in 120 necropsies ton, who performed a duodenojejunostomy in 1910 for of patients dying with acute dilatation of the stomach.9 chronic gastromesenteric ileus followed by complete The earliest references to chronic dilatation of the cessation of symptoms. duodenum appear to have been made by Glénard10 Bircher,1T like Finney, looks on duodenojejunal ileus (1889) and Kundrat11 (1891), both of whom stated as a clinical entity. He reports three patients with that a persistent, incomplete obstruction of the duo¬ recurrent attacks of vomiting, and duodenal stasis on denum by the root of the mesentery was not uncom¬ Roentgen-ray examination. Operation in each of these mon and led to a gradual dilatation of the duodenum cases showed dilated duodenum with stomach of nor¬ and stomach. Albrecht1 (1899) mentioned two cases mal size, ileum and jejunum practically empty, and a which he thought might have been instances of this more or less rigid cord causing constriction at the condition, and Robinson12 of Chicago (1900) asserted mesenteric slit. that in the course of several hundred postmortem Since 1912 only a few isolated reports have appeared examinations he had met with fifteen or twenty dealing with chronic dilatation of the duodenum. examples of gastroduodenal dilatation due to such Barber18 refers to the coincidence of dilatation of the incomplete obstruction. duodenum and ileac stasis as recognized by Roentgen- Connor,3 writing in 1907, states that nothing is ray studies on gastro-intestinal cases, and reports his known of the clinical manifestations of such chronic experimental studies on dogs. He found that incom¬ obstruction, but calls attention to the instances of plete obstruction of the extreme caudad ileum gave duodenal dilatation reported during the preceding two rise to dilatation of the cephalad duodenum but he years by three American surgeons (Finney,13 Mayo,14 questions whether this result is mechanical or a neuro- and Ochsner15) and suggested that these cases were muscular reflex. probably due to mesenteric obstruction. Melchior,19 in discussing arteriomesenteric occlusion Finney, in his brief report, simply called attention to of the duodenum, emphasizes the fact that the organs cases seen the five he certain in preceding years which in the abdominal cavity either float or rest on the believed had not been mentioned in that the literature, organs below, and these on the floor of the pelvis and is, dilatation of the duodenum with a patent condition the abdominal wall. He takes exception with those All cases were with of the pylorus. of his associated authors who maintain that the viscera are suspended and that was done seemed to visceroptosis nothing by their ligaments or mesentery, although there is relieve the symptoms (chronic indigestion with nausea nothing in his argument to disprove the result of trac¬ and one of his cases was vomiting). Only diagnosed tion on the mesentery in visceroptosis. before necropsy. Gastr'o-enterostomy was done in Dilatation of the duodenum in childhood, except in several instances but was found wanting, and gastric cases of congenital atresia, is apparently rare. Two success. in lavage gave only partial He referred his instances, however, are reported by Frank.20 One of the benefit to be derived from report to possible pos¬ these was demonstrated at operation in a girl 11 tural treatment. He concluded that the condition is a months old in whom there was marked dilatation of In his definite clinical entity. the discussion of report the stomach and the duodenum to the point where it the of and operations jejunostomy duodenojejunos- was crossed by the root of the mesentery. Beyond the tomy were suggested. root of the mesentery the intestine was collapsed. Ochsner's two papers, profusely illustrated from Complete recovery ensued and the child, at 18 months called attention to the careful dissections, hypertrophy of age, was well and strong and had no digestive dis¬ which was sec¬ of the walls of the duodenum evidently turbances. In a second child, 2 years old, suffering ondary to the chronic obstruction that he failed to from recurring attacks of vomiting, Frank diagnosed observe or interpret. Mayo simply referred to the chronic dilatation of the duodenum on Roentgen-ray instances of dilated duodenum reported by Finney and examination and advised operation, which the parents Ochsner and stated that he, too, had observed such a refused. From the symptoms and Roentgen-ray find¬ condition. he felt certain that the occlusion of the duodenum that ings Bloodgood,5 writing in 1912, says he recognized was due to mesenteric constriction. first case chronic dilatation of the duodenum in his of The symptoms of chronic dilatation of the duo¬ 1906 the course of an during exploratory operation. denum are those of an constriction, that was not relieved and the came infrapapillary The obstruction patient an entrance the common after He is, obstruction below the of to necropsy twenty-seven days operation. and the duct into this of describes a second similar fatal case in the service pancreatic portion the bowel. may be as of a in which a was They conveniently grouped colleague pyloroplasty performed follows : without the of duodenal relieving symptoms (vomiting 1. or In most In of these there was Persistent, recurring, vomiting. contents). both patients great in dilatation of the duodenum associated with viscerop¬ instances the vomitus contains bile, often consider¬ tosis. He then five cases in which able quantity. reports subsequent 2. Pain in the of the he recognized at operation the relation of the duodenal upper part abdomen, generally referred to the As a this dilatation to ptosis of the colon, and was able to relieve right hypochondrium. rule, four of these patients completely by resection of the is described as an aching or dragging pain, but it may right half of the colon and ileocolostomy. Bloodgood be severe so as to suggest biliary colic, or, in other instances, it simulates the pain of peptic ulcer with 9. Laffer: Ann. Surg., Philadelphia, 1908, 48. food-relief. 10. Gl\l=e'\nard:De l'Enteroptose, Presse m\l=e'\d.,Belge, 1889. irregular 11. Kundrat: Ueber eine seltene Form der inneren Incarceration; 351. 16. Stavely: Surg., Gynec. and Obst., 1910, 11, 288. abstr., Wien. med. Wchnschr., 1891, 41, 843. 12. Robinson: Am. Pract. and News, 1900, 20, 124. 17. Bircher: Zentralbl. f. Chir., 1912, 39, 13. 17, 37. 18. Barber: Ann. Surg., 1915, 62, 433. Finney: Johns Hopkins Hosp. Bull., 1906, klin. No. The 14. W. Chronic Ulcer of the Stomach and First Portion of 19. Melchior: Berl. Wchnschr., 1914, 51, 38; abstr., Mayo, J.: Oct. 1611. the Duodenum, The Journal A. M. A., Oct. 21, 1905, p. 1211. Journal A. M. A., 31, 1914, p. 15. Ochsner: Ann. Surg., 1906, 43, 80. 20. Frank: Zeitschr. f. Kinderh., 1913, 9, 99.

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/03/2015 3. "Habitus enteroptoticus," often associated with The treatment of chronic dilatation of the duodenum exaggerated lordosis. may be either medical or surgical, depending on the 4. Obstinate constipation is the rule, although this degree of obstruction. In the simpler cases a well may not be a feature of the case. Occasionally the conducted rest-cure, with increase of weight and the stools are colorless and relatively free from bile. deposit of fat in the various supporting tissues of the 5. Vague toxic symptoms are common. Headache abdominal cavity, brings about an entire cure of the is frequently a prominent symptom. These patients condition. In more obstinate cases postural treatment appear to be peculiarly sensitive and of an unstable has been successful. By placing the patient in the nervous temperament. In marked cases starvation knee-chest position, the weight of the stomach and with acidosis develops and leads to a fatal termination. intestines pulls the viscera toward the anterior abdom¬ The chief clinical interest in chronic dilatation of inal wall, thus tending to release the compression on the duodenum lies in the fact that the symptoms are the duodenum. The knee-chest position may be main¬ almost invariably misinterpreted. In one group of tained for fifteen minutes every two hours, the patient cases with lesser grades of obstruction no obvious lying on his face and abdomen in the intervals. If the cause is noted for the condition, and it is therefore vomiting stops for a few hours, the pleasanter left thought to be functional. As I look back on a large side position may be ordered, with the hips elevated. number of thin, neurotic, enteroptotic women whom This treatment may be supplemented by frequent I relieved of "hysterical vomiting" by means of rest washing out of the stomach with the tube. cures with psychotherapy, forced feeding, massage, In the severer cases, where starvation and acidosis etc., I now feel convinced that my complacency in the threaten, medical measures are entirely inadequate. successful outcome in many instances was due to the From a review of the scattered case reports in the increase of weight which such patients obtained, literature one finds that several widely different sur¬ thereby relieving the visceroptosis and the chief factor gical procedures have been adopted with subsequent in chronic mesenteric ileus. The longer one prac¬ cure of the patient. Some operators have succeeded tices medicine with an open mind and an inquisitive in widening the duodenal slit in the mesentery. In instinct, the more one questions the diagnosis of other cases duodenojejunostomy has been effectual. hysteria. Furthermore, a clinician has only to see Again, resection of the right half of the colon with the necropsy on one patient with an unrecognized ileocolostomy has been done with complete relief to chronic mesenteric obstruction, such as the first case the distressing symptoms. With few exceptions, the in the series reported above, to appreciate what a real operation of gastro-enterostomy has signally failed in condition it is and how it is possible for the lesser gastromesenteric ileus. More careful study of this forms of obstruction to pass undiagnosed except under form of chronic intestinal obstruction will probably the title of neurosis. At once there comes to my mind result in the adoption of a uniform method of pro¬ the sensations of a well-known neurologist who, in cedure applicable to these cases. demonstrating several patients with disseminated sclerosis that had been previously treated for hysteria, CONCLUSION finally exploded with the remark, "Gentlemen, there We have in chronic dilatation of the duodenum a is a in hell for the doctor who clinical entity, with a definite symptomatology and special compartment due treats disseminated sclerosis as hysteria." characteristic Roentgen-ray findings, to compres¬ sion of the terminal of the the In a second group of cases the clinical picture is portion duodenum by root of the It is a feature of cases very of cholecystitis. In the absence of mesentery. many suggestive of is a Roentgen-ray studies this -is the usual pre¬ visceroptosis and remediable disease subject to proper mechanical treatment. operative opinion in patients with a rather pronounced proper obstruction. The attacks of abdominal pain may 603 East Grace Street recur over a period of months with finally insistent demands for surgical relief. In addition to the cases ABSTRACT OF DISCUSSION I have had reported in this paper, six patients with Dr. Lewis A. Conner, New York : Dr. VanderHoof has chronic dilatation of the duodenum due to adhesions rendered us a real service in bringing to our attention so and abnormal peritoneal folds, five of whom came to clearly this clinical picture which, for most of us, cer¬ operation with the diagnosis of chronic cholecystitis. tainly is not one which is apt to come into mind. Duodenal In the sixth patient peptic ulcer was thought to be obstruction and duodenal dilatation we have been more familiar with as an acute condition in association with acute present. dilatation of the stomach. The chronic type is perhaps really In a third group of cases with persistent incomplete is almost continuous and leads the more important and frequent type, and is one to which obstruction, vomiting attention certainly should be drawn. The mechanical factors to the death of the In such cases the abun¬ patient. involved are still, it seems to me, very obscure. There can entrance of bile into the stomach dant and constant be no doubt that the obstruction by the root of the mesentery the is almost pathognomonic. In addition, stomach, and by the superior mesenteric artery is a real one ; but when even when it has been completely emptied the evening one attempts to explain what the conditions are that bring before, may be found the next morning to contain large about such an obstruction, there are many difficulties. Cer¬ quantities of bile-stained fluid. While one expects and tain things are obviously necessary ; if the mesentery is to frequently finds more or less abdominal distention in pinch the duodenum, it must be tight and there must be in a certain direction. Those conditions are fulfilled these cases, yet the abdomen may be peculiarly traction the small intestine in the true and retracted and soft all the illness, as in Case by being pelvis being- through cannot be in the true unless it is Dr. 1 of series. empty ; it pelvis empty. my Bloodgood and others have emphasized the drag of a mobile in those cases discovered at The diagnosis, except caput coli as an important factor. Apparently the mesentery can be operation or necropsy, reached only by having must be neither too short nor too long in order to constrict the condition in mind as a clinical entity, and then the duodenum. An increased lordosis of the lumbar spine confirming it by a competent Roentgen-ray exami¬ or downward displacement of the terminal portion of the nation. duodenum certainly predisposes to constriction. Undoubt-

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/03/2015 edly some of the cases which have been classed as functional logic examination revealed a stenosis of the duodenum, which recurrent vomiting are instances of constriction of this ter¬ justified reference to the surgical service for operative relief. minal portion of the duodenum. The difficulty is to say just When the viscera were exposed the stenosis was recognized which of them are, because we know that they are not all of as spastic in nature, similar constriction occurring in the that type. It seems to me important to emphasize the fact stomach, and the site varied with succeeding peristaltic that the obstruction and not the dilatation is the important waves. The attacks of pain and digestive distress in this thing. We will have to rely chiefly on the Roentgen-ray find¬ instance were incident to visceral crises, and illustrate that ings for diagnosis. There are, however, a few things to bear in the condition referred to in the paper may be simulated in mind : the difficulty of diagnosis is greater because of the organic nervous diseases. fact that cases of persistent vomiting from whatever cause Dr. Franklin W. White, Boston : Since this condition of are apt to be of duodenal type. Any persistent vomiting soon chronic duodenal obstruction has been so clearly described, it becomes intestinal in character ; the vomitus contains bile is well to remember its extreme rarity even when the diges¬ and pancreatic juice and is alkaline and has most of the tive organs drop down very low. This may give a sharp characteristics of duodenal obstruction, so the type of vomit¬ duodenal angle, but the angle rarely causes obstruction. The ing cannot be relied on as evidence of actual obstruction. duodenal angle may be compared with the splenic flexure, One other matter is important to bear in mind : When there which is usually sharp but not obstructive. We must consider is high intestinal obstruction, great diminution or suppres¬ function and not 'anatomy. I am sure the time is now at sion of the urine is one of the common and reliable symp¬ hand when the diagnosis of duodenal obstruction will be toms, and it seems to me that the behavior of the urine may made, not at operation or necropsy, but by the Roentgen ray. help us to make the diagnosis and give us a clue to the No other method shows so well the place and degree of progress of the condition and the necessity for surgical obstruction in the digestive canal. interference. I should like to ask how much residue was left in the Dr. George R. Satterlee, New York: There is one impor¬ duodenum and how much delay in emptying the stomach was tant point to bring out. We have all seen duodenal obstruc¬ found in these cases. tion or duodenal dilatation due to obstruction around the The symptoms will prove a poor guide in diagnosis. Many ileocecal region, as Dr. Bloodgood has pointed out. I have of these patients have congenital asthenia and ptosis, the been struck by the number of patients who have a duodenal symptoms of which blend with and cover those of dilated The dilatation as shown by the Roentgen ray, and who have duodenum. Roentgen ray will help us most in diagnosis. The treatment merely an enteroptosis ; also by the fact that this is connected is largely that of marked ptosis. Dr. Douglas : Conner is with atonic dilatation of the cecum ; these two things often VanderHoof, Rjchmond, Va. Dr. well to discuss this In his go together. In visceroptosis there is a drag on the mesen¬ qualified subject. monograph pub¬ lished ten he went into the causes of tery, and we have a great many reflex reactions through the years ago thoroughly acute dilatation of the stomach and duodenum. The sympathetic nerve system. Now the symptom of dilated duo¬ thing that at that time was Dr. Conner's statement denum is often pain, and I should like to cite a case in which caught my eye that was known of the of the pain was in the liver region and the patient was operated practically nothing symptomatology chronic obstruction in the duodenum. As a matter of fact, on for relief of pain, and there was found a long, ptosed gall¬ references in the literature show case bladder and enteroptosis. Later, the patient was operated only sporadic reports. Dr. White is correct, I am sure, in the on for appendicitis and was finally relieved by the proper quite emphasizing as well as the anatomy of such forms of obstruc¬ treatment for enteroptosis, namely, posture. If we cannot physiology tion. In answer to his question as to how much residue may decide that it is an operative case, we can place this patient be left in the stomach in these cases and how much delay in proper posture by elevation of the foot of the bed, abdomi¬ may occur in the duodenum, I should like to read a brief nal support and proper treatment of the constipation, etc., description of the Roentgen-ray picture in these cases. which relief to the and is worth It (See may give pain, trying. reference to Jordan's article, which had not been read when seems to me á great many of these enteroptotics are treated the paper was presented.) Barber's experiments showed that for neuroses. partial constriction of the caudad end of the ileum produced Dr. F. B. Turck, New York : The of these presentation dilatation of the cephalad end of the duodenum. He ques¬ cases because it the clini¬ eleven is very important, opens up tions whether the result is mechanical or due to a neuro- cal view of scientific facts which have been recently investi¬ muscular reflex. To my mind the effect is mechanical, asso¬ gated in this country. JDr. Senn of Chicago brought out, in ciated with the mesenteric drag and subsequent duodenojejunal 1888, some experimental facts on intestinal obstruction, and kinking. proved that mechanical obstruction alone cannot produce symptoms. Senn also showed that not until the venous cir¬ culation is interrupted do pathologic conditions arise. The Fermi's Modification of Pasteur Treatment of Rabies.— work of Dr. Whipple and Dr. Hartwell has shown that com¬ C. Fermi is professor of hygiene and chief of the Pasteur plete obstruction is necessary before any symptoms can be Institute of the University of Sassari, Italy. He has recently produced. The fact that there is, in duodenal disturbance, a published the full details of what he calls the "new Italian dilatation of the cecum with atony shows that it is not merely method of antirabies treatment," although it has been in use a mechanical question. It points to some more general func¬ since 1909. The vaccine is a 5 per cent, emulsion of the most tional derangement. We found through our experimental virulent fixed virus, made from the brain (rabbit or dog), work that colloid material (undigested albumin, such as rendered avirulent with 1 per cent, phenol (carbolic acid). He white of egg or bacteria in suspension) can penetrate uses mixed with this vaccine an antirabies serum derived from unchanged into the walls of the intestines and can pass the horse, prepared with this vaccine for the antigen (two along the submucous tissue cephalad. Reaching the upper daily injections of 10 c.c. of the vaccine) for a month; pause intestinal tract they are split up by the action of the power¬ of two weeks ; then continued another month ; pause of ful enzymes in the wall, and toxic effects are produced. We twenty days ; withdrawal of from 3 to 6 liters of blood. The produced symptoms of degeneration and fatigue in the mus¬ antirabies serum thus obtained is mixed with three times its cle cells, and the two conditions are identical in man and volume of the vaccine, and after the mixture has stood on animals. We are dealing with biologic problems in these ice for twenty-four hours, 3 c.c. are injected subcutaneously cases of atonic dilatation, and we must treat them along in the morning and 3 c.c. in the evening. This is repeated biologic lines, and not look on them as being simple prob¬ for five or ten days, and then, for an additional twenty or lems in mechanics alone. We are dealing with physiologic fifteen days, the vaccine alone is injected. A set of vials for laws, which we must meet with physiologic methods of home treatment comprises ten or twenty vials of the sero- treatment. vaccine mixture, and forty or twenty of the vaccine alone. Dr. W. L. Bierring, Des Moines, la. : I should like to The 164 page pamphlet describing the technic and the com¬ add an observation to this discussion. In a case of tabes parative tests and experience with it was issued as a supple¬ with attacks of epigastric pain and vomiting, the roentgeno- ment to the Annali d'Igiene, 26 (Via Sistina, 14, Rome).

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