Duodenal ulcers in infancy / L. emmett Holt.

  • Holt, L. Emmett (Luther Emmett), 1855-1924.
Date:
1913
Catalogue details

Licence: In copyright

Credit: Duodenal ulcers in infancy / L. emmett Holt. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    tymiianitic, only moderately distended, the cireuinference being 13% inches. The lower border of the liver was felt just below the costal margin; the spleen was not palpable. Xo abnormal masses were felt. The child was j)laeed on a milk formula having the following percentages: Fat, ff.OO; sugar, 5.00; protein, 1.20 iier cent. This patient also lived eight days after entrance into the hospital. During this time the temperature was much of the time subnormal. 94 F. being noted on one occasion. The urine gave a strong reaction to bile, but contained no blood or casts; urobilinogen test negative. All the stools were white, pasty, oli'ensive and large for the food taken. The presence of bile salts could not be demonstrated. The stools contained immense quantities of fat which formed approximately 90 per cent, of the dried residue. This was chiefly in the form of soaps, although there was also a large excess of neutral fat. There was both macroscopic and occult blood in the stools. At no time was there diarrhea, and there was no vomiting of blood. Both Wassermann and tuberculin tests were negative. Blood examination at the time of admission showed: Hemoglobin, 55 per cent.; red cells, 3,900,000; white blood- cells, 15,000; polymorpbonuclears, 23.3 per cent.; lymphocytes, 70.3 per cent.; eosino])hils. 0.3 per cent. One week later the hemoglobin was but 20 per cent, and red cells, 1.700,000. The duodenal catheter was j)assed without much dilbculty to ascertain the presence of bile. None could be obtained but on withdrawing the tube it was found to contain a blood-clot. This was repeated three or four days later and a larger clot obtained. The child grew ])rogressively worse and died of exhaus- tion. From the presence of blood in the stools and in the duodenal catheter the diagnosis of duodenal ulcer was made. Necropsy.—Body emaciated and deeply jaundiced, and all the internal organs deeply bile stained; a small area of bronchoi)neumonia in right upper lohe; heart normal; pancreas and peritoneum normal; spleen, normal in size and appearance. Liver, dark greenish color, 7iot enlarged and not hard; capsule thickened, espe- cially at the border; slight increase in the connective tissue; no recent exudate; gall-bladder contained thick, dark green Idle which could easily be ex]>ressfd tbrough tbe duct into tbe duodenum. Cystic and hei)atic duets a]>peared normal. Duodenum showed two small round “i)unched-out” ulcers, each about 5 mm. in diameter. One was situated just below the pylorus (Fig. 1). It extended quite to the peritoneal coat; at its margin was seen a small blood-clot from a bleeding vessel; a large blood-clot in the duodenum lower down. The other was similar in ap])eaiance and situated 1 cm. lower down in the duodenum. The rest of the . intestine, both small and large, showed areas of congestion and enlargement of j the solitary follicles. The kidneys were normal, except jaundiced. Cultures ' from the lung showed Gram-negative bacilli and ])neum<icocci. ^Microscopical examination by Dr. tVollstein showed a loss of epithelium of the mucosa, edema of the mucosa ami suhmucosa, but no cellular infiltration. The muscular and peritoneal coats were normal. The liver showed no increase of connective tissue. The blood vessels and capillary bile ducts were normal. Ca.se 3.—nicer of the duodenum; concealed hemorrhaf/e; sudden death. , Hist on).—(M. F., a female child, 4 months old, admitted to bosi)ital on account of diarrhea and vomiting which had lasted one week. Family history unimpor- tant. For the fii'st two months the baby had been breast fed and did well; then had been juit out to board and had not thriven. The bowels had been generally ; loose, but no vomiting had been noted till one week before admission. Stools thin and green, four or five daily; no fever, but steady loss in weight. On admission the child weighed S i)ounds, 14 ounces; fairly well develojied; did not appear acutely ill; heart and lungs normal; sjjleen palpable one-half inch below costal margin; liver, enlarged, the lower border 1% inches below the costal margin; M'assermann negative. Blood: hemoglobin, 00 per cent.; red cells, ' 4.40(i'.00(); white cells, 14,000; polymor])honuc'ears, 40 per cent.; lymphocytes, 00 jier cent. i