4
CONSTIPATION IN ADULTS AND CHILDREN
(From Luschka, " Die Lafie tier Uaiichorgane," etc.)
Frontispiece,
19, Right lobe of the livei"; 20, Quadrate lobe; 21, Left lobe of the liver; 22, The suspensory (broad) ligament of the liver, cut off; 22*, Fundus of the gall-bladder; 23, Oesophageal (upper) oriflce of the stomach ; 2i, Cul-de-sac of the stomach, partly overlaid by the left lung; 25, Pyloric end of the stomach; 26, Section of the stomach which lies in the epigastrium, and is partly covered by the liver ; 26 *, Arteria gastro- epiploica dextra, corresponding to the course of the greater curvature of the stomach ; 27, Csecum ; 28, Appendix Vermiforrais ; 29, Ascending colon ; 30, Right colic flexure ; 31, Transverse colon ; 32, Left colic flexure ; 33, Descending colon ; 34, Dotted lines, showing position of sigmoid flexure underneath the small intestines ; 35, Small intes- tines in the arrangement most commonly found ; 36, Obliquely ascending end of small intestines ; 37, Summit (apex) of bladder covered by peritoneum ; 38, Anterior and lower portion of bladder (in a state of moderate distention and reaching beyond upper border of pelvis) free from peritoneum.
CONSTIPATION ^
m ADULTS AND CHILDREN
WITH SPECIAL REFERENCE TO
HABITUAL CONSTIPATION AND ITS MOST SUCCESSFUL TREATMENT BY THE MECHANICAL METHODS
BY
H. ILLOWAY, M.D.
FORMERLY PROFESSOR OF THE DISEASES OF CHILDREN, CINCINNATI COLLEGE OF MEDICINE AND SURGERY ; FORMERLY VISITING PHYSICIAN TO THE JEWISH HOSPITAL, CINCINNATI; ETC., ETC. MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK OF THE NEW YORK COUNTY MEDICAL ASSOCIATION, ETC.
THE MACMILLAN COMPANY
LONDON: MACMILLAN & CO., Ltd. 1897
AH riffhin reserved
Copyright, 1897, By the MACMILLAN COMPANY.
NortooaH JPtcBS
J. S. Cashing & Co. - Berwick Si Smith Norwood Mass. U.S.A.
TABLE OF CONTENTS
Part I
SECTION I CHAPTER I
TO
Anatomy of the Intestines. (With reference mainly to the large bowel; its position in the abdominal cavity; the internal arrange- ment of its mucous membrane.) The vessels. The nerves — show- ing the relation of the bowels to the cerebral and the spinal centres
CHAPTER n
Platus
CHAPTER ni
Intestinal Peristalsis. Defecation
CHAPTER IV
I'^ces (appearance thereof under the microscope) - . ' .
CHAPTER V
Definition; Etiology; Classification
CHAPTER VI
Acute Constipation ; Etiology. {En parmthese, an account of for- eign bodies that may cause such, with histories of cases to illustrate the mode of treatment when sharp bodies, as knives, etc., have been introduced) ..........
CHAPTER VII
"Chronic Constipation ; Etiology. The various maladies that may give rise thereto — Foreign bodies (with histories of cases) — Mal- formations of the intestines — Dislocation of the intestine — Essen- tial primary atrophy of the intestine
vii
Vlll TABLE OF CONTENTS
CHAPTER Vm
Spastic Constipation. Enterospasin — Enterospasra and atony — Spasmodic stricture of the rectum — Spasmodic contraction of the sphincter of the anus without fissure — Irritable sphincter . . 94
CHAPTER IX
Atony OF THE Intestine. Causes — Mode of action . . .105
CHAPTER X
Symptomatology. General and local symptoms .... 112
CHAPTER XI
Diagnosis. Methods of examination ; percussion, palpation, inflation
— Faeces, microscopic examination of.
Prognosis 132
CHAPTER XII
The Consequences of Constipation. Haemorrhoids — Anal Fis- sure — Typhlitis — Appendicitis — Enteritis membranacea — Proc- titis— Fsecrfl tumors — Dislocation of the bowel — Ulceration of the bowel — Ulceration with hypertrophy — Diverticula . . 166
CHAPTER XIII
The Consequences of Constipation, Cont. Diarrhoea with consti- pation — Ileus — Jaundice — Torpid liver — Atony of the stomach
— Auto-intoxication 176
CHAPTER XIV
The Consequences of Constipation, Coni. Disturbances of the
nervous system — Pyschoses — * * * — Chlorosis . . ■ 185
SECTION 11— TREATMENT CHAPTER XV
Treatment of Constipation due to Atony of the Intestine. Hygienic rules — Dietary regulations ; diet list — Exercise ; rules for same
CHAPTER XVI
Treatment of Constipation due to Atony, Cont. Massage ; gen- eral technic of — Special manipulations — Schedules of manipu- lations— Duration of treatment — Instrumental massage . • 243
203
TABLE OF CONTENTS
ix
CHAPTER XVII
TO PAGE
Treatment of Constipation due to Atony, Cont. Swedish move- ments — Machine gymnastics — Centra-indication to massage . 264
CHAPTER XVni
Hydrotherapy. Special procedures — Schedule of temperatures for
water 283
CHAPTER XIX
Electricity. Modes of application 299
CHAPTER XX
Medicines. Nux vomica (Strychnia) — Calabar bean (Physostigma) — Ergot — Zinc — Ammonii chloridum
305
CHAPTER XXI
Effects of Treatment; Complication 308
CHAPTER XXII
Treatment of Conditions related to Atony. Ileus — Paraly- sis of the intestine — Atony of the rectum ..... 317
CHAPTER XXIII
Treatment of Atony of the Intestine dependent upon Morbid Processes. I. Constipation dependent upon intestinal catarrh — II. Atony from morbid processes elsewhere: 1. Xeurasthenia ; 2. Debility after protracted maladies ; 3. Disease of the heart . 324
CHAPTER XXIV Treatment of Spastic Constipation 333
CHAPTER XXV
Treatment of Constipation due to Irritable Rectum . . 340
CHAPTER XXVI
Treatment of Constipation dependent upon Genito-urinary
Troubles 343
CHAPTER XXVII Fissure of the Anus 345
TABLE OF CONTENTS
CHAPTER XXVIII
-surgi-
H^MORRHOiDs. Relief of the constipation due to them — Non-i
cal treatment of ggg
CHAPTER XXIX Oil Injections. Technic of 359
CHAPTER XXX
Other Methods of Treating Constipation (recommended by various writers). 1. Stretching of the sphincter aui; 2. Applica- tion of boracic acid to the anus; 3. Treatment by river-gravel (Flusskiesel) ; 4. By suggestion 365
CHAPTER XXXI Treatment of Constipation in Old People 369
CHAPTER XXXII Formulary 383
Part II
CONSTIPATION IN INFANTS AND CHILDREN
CHAPTER I Introduction ; Classification.
Congenital Constipation. Malformation of the rectum and anus
— Of the colon — Of the small intestines — Malplacement . . 412
CHAPTER n
Acquired Constipation.
Acute Constipation, Etiology 418
CHAPTER III
Chronic Constipaton, Etiology 422
CHAPTER IV
Habitual Constipation, Etiology . . . o c . • 428
TABLE OF CONTENTS XI CHAPTER V
TO PAGE
Habitual Constipation due to Atony, Cont. .... 434
CHAPTER VI
Habitual Constipation due to Atony, Cont. Habitual constipa- tion in older children 437
CHAPTER Vn
Symptoms and Diagnosis 440
CHAPTER Vni
Treatment of Constipation due to Atony of the Intestine (Infants). General measures — Special measures (remedies, injec- tions) — Massage — Secondary measures 455
CHAPTER IX
Treatment of Constipation due to Atony of the Intestine,
Cont. Older children 458
CHAPTER X
Some Anatomical Considerations ....... 464
CHAPTER XI
Massage. Preliminary considerations 469
CHAPTER XII
Massage. Technic of manipulations for infants and young children 480
CHAPTER XIII
Spastic Constipation.
Fissure of the Anus 484
Formulary
CHAPTER XIV
488
LIST OF ILLUSTRATIONS
Part I
PAGE
Frontispiece, showing the abdominal organs in position.
The duodenum and surrounding structures 4
The c£ecum, showing funnel-shaped terminal extremity of the ileum,
and the appendix vermiformis 7
The large bowel in position 8
The caecum laid open, showing orifice of appendix vermiformis . . 10
The sigmoid flexure . . 12
The sigmoid flexure 13
The external sphincter of the anus, perineal muscles in man ... 15
Sacculi Horueri 18
Diagram of the nerves of the intestinal tract .21
The plexus of Auerbach 23
The plexus of Meissner 24
The male perineum, showing distribution of nerves .... 25
Normal fa3ces 41
Human colon, congenital giant growth . 67
Diverticulum, congenital, of the sigmoid flexure 77
Illustration of enteroptosis . 80
Upward dislocation of transverse colon 81
Dislocation of the sigmoid flexure to the riglit 85
Abdomen, where to examine 110
Arrangement of apparatus for inflating the bowel with gas . . . 122 Arrangement of apparatus for inflating the bowel with air . . .123
Crystals of haematoidin 127
Teichmann's haemin crystals 127
Colored Plate, showing microscopic appearance of some constipated
faeces, between pages 128 and 129
Demi-schematic view of the external surface of the ampulla of tlic
rectum
xiii
xiv
LIST OF ILLUSTRATIONS
Demi-schematic view of the internal surface of the ampulla of
rectum
False diverticula, of the large bowel Distention diverticula, of the small intestine Diverticulum of the ileum Bandages for the abdomen Abdominal bandage .... Effleurage with the tips of tlie Augers Frictions with the thumb . Petrissage with the thumb . Petrissage with the tliumb and finger
Diagrammatic illustration of position of patient for massage Division of the belly with one hand , Division of the belly with two hands Eolling of the belly with one hand Rolling of the belly with two hands . Petrissage of the abdominal walls TheKammgriflr . Kneading of the belly . Punctation .... Circular effleurage Position of hands for operator
To brealv up indurated faeces in caecum and ascending colon To breali up indurated fasces in transverse colon Manipulation for ascending colon, liver, and gall bladder Transfer movement, for caecum and ascending colon Transfer movement, for transverse colon .... Transfer movement, for descending colon and sigmoid flexur Position of hands for petrissage, of sections of colon Position of hands for petrissage, of sections of colon . Kneading and raising of sigmoid flexure Vibration of solar plexus . Hacliing of the belly . Clapping of the belly . Tapotement i\ I'air comprini6 Beating of the sacrum Kahn's roller
Figs. 1-10, Active movements
the
LIST OF ILLUSTRATIONS
XV
PAGE
Figs. 1 1-18, Movements against resistance 250-2o5
Figs. 19-23, Passive movements 2o7-258
Fig. 24, Row boat of Sachs 2C1
Fig. 25, Row boat of Ewer
Fig. 26 a, Movements witli Saclis restaurateur 261
Fig. 26 b, Goodyear's pocket gymnasium 261
Outline of enlarged spleen 262
Self-acting clysopump 265
Force pump
Application of the wet sheet 274
Sprinklers • ^''^
Rectal electrodes
Bipolar rectal electrodes 289
Atzperger apparatus ^37
Winternitz's device 338
Bottle for generating carbonic acid 339
Psychrophor 341
Hajmorrhoidal bandage 349
Tip for syringe (for oil injection) 355
Rectal bougies • 361
Whitehead's instrument 361
Part II
Frontispiece I. Abdomen of infant twelve days old laid open, small
intestines in situ. Frontispiece II. Same, showing large bowel, liver, and stomach.
Congenital contraction of the ascending and transverse colon, etc. . 395
Congenital obliteration of the small intestines ...... 401
Ileum with diaphragms 407
The abdominal viscera of a new-born infant held in position . . 462
Diagram of the above 4G3
Diagram showing direction of manipulation 471
Manipulation II. for infants 471
Diagram showing direction of manipulation 472
Manipulation III. for infants 473
Manipulation IX., thumb movement 476
PART I CONSTIPATION IN ADULTS
COIfSTIPATION m ADULTS
SECTION I CHAPTER I
ANATOMY OF THE INTESTINES
The part of the human body that principally concerns us here is the intestinal canal, consisting of two distinct and characteristic parts, — the small intestines and the large bowel.
The small intestines constitute by far the major part of the intestinal tract. The average length in the adult male (between the ages of twenty and fifty) is twenty-two feet, six inches ; in the female it is twenty-two feet, four inches. Exceptionally it is found, both in the male and female, longer or shorter by some feet.
The intestinal tract proper begins at the stomach, from which it is separated by the sulcus pyloricus, with that portion known as the duodenum. Ever since the days of Herophilus the small intestines have been divided into three parts, — the duodenum (twelve fingers, eight to ten inches), the jejunum, and the ileum. There is, how- ever, no line of demarcation that separates the duodenum from the jejunum, or any distinctive feature by which to
3
4
CONSTIPATION IN ADULTS
recognize the one from the other. Luschka has therefore proposed that the duodenum and jejunum be grouped together as one part and be called the pancreatico-bilious intestine (intestinum pancreatico-biliosum).
The duodenum takes its origin at the pyloric extremity of the stomach, on the right side of the epigastrium, about the level of the last dorsal vertebra, and ends on
■2 3
The Duodenum and surrounding Structures. {Sappey.)
1 Para horizontalis superior, thrown back to the right; 2, Pars desce7i<lens or verticalis ; 3, Pars horizontalis ivferior.
the left of the spinal column, about the level of the third lumbar vertebra, in the jejunum. Between the points here described it changes its course three times and is therefore divided into three segments, — some have it four, — the pars horizontalis superior, the pars descendens or verticalis, and the pars horizontalis inferior. The fourth part described by some is the pars ascendens.
ANATOMY OF THE INTESTINES
5
The pars horizontalis superior. Beginning at the stomach, as already described, it runs outward and some- what upward to the right in a horizontal direction, with a tendency to obliqueness. The position varies, of course, considerably with the movements of the stomach, becom- ing more transverse when the longitudinal fibres of that organ are contracted, and more oblique when the stomach is dilated. The position undergoes change in gastrop- tosis, whether this be partial, as when the pyloric portion alone is dislocated, or complete. This portion of the duo- denum is the widest of this section of the small intestine and is about two or three inches in length. It is some- what bottle-shaped, dilated more at its upper extremity to form the antrum duodenale. It is covered by the lobus quadratus and the right lobe of the liver. This segment is freely movable and is almost completely invested by the peritoneum. The pars verticalis (de- scending segment) runs down in front of the right kidney as far as the third lumbar vertebra. It does not descend in a straight line, but makes a gentle curve and merges almost imperceptibly into the inferior transverse portion. Joined to this latter part it gives to the duodenum the configuration of a horseshoe with the convexity looking to the right and the concavity to the left. In the con- cavity is received the head of the pancreas. On the inner surface of the vertical segment just below its middle is the orifice of the ductus communis choledochus, and just a little above this the separate orifice for the duct of the pancreas. It is covered by peritoneum on its anterior surface only. The pars horizontalis inferior, the longest and narrowest, part of the duodenum, passes over trans-
6 CONSTIPATION IN ADULTS
versely from the right side to the left and at the left harder of the spinal column ends in the jejunum. That which by some is described as a fourth change in direc- tion, or fourth segment, is the ascent made by the terminal extremity of the duodenum from the third to the second lumbar vertebra, at which point the jejunum may be said to begin. It has a partial investment of peritoneum on its anterior surface. It is covered in front by the transverse mesocolon and crossed by the superior mesenteric vessels ; it lies upon the aorta, vena cava, and the crura of the diaphragm. Above it is the lower border of the pancreas.
Jejunum and Ileum. — The jejunum is two-fifths of the residue of the small intestine. It begins at the point already described, descends, makes numerous convolu- tions, and merges into the ileum. The ileum is the residue of the small intestine, and is the narrowest portion of it. The gyri or ansae, which these two segments form, are very numerous, and they lie closely packed together. They are arranged in a very irregular form, from left to right. Leaving the duodenum, they fill the contiguous left epigastric and umbilical regions, then the left hypochondriac and left lumbar regions, descend into the pelvis, reascend into the left iliac, pass over the hypogastric into the lower umbilical, right hypochondriac, and right lumbar regions. The ileum terminates here in that portion of the large bowel known as the caecum. This terminal extremity is rather funnel- shaped, the wide portion of the funnel directed toward the ileum.
By means of the mesentery, which is a fold from the
ANATOMY OF THE INTESTINES
peritoneum, and which with its two layers, the ascending and descending, forms the peritoneal covering of these two segments of the small intestine, they are hung up, as it were, on the spinal column.
The capacity of the small intestine is equal to six litres (about twelve pints).
The Large Bowel. — The large bowel, intes- tinum crassum seu am- plum, is about five feet in length, with occa- sional variations as in _ ^ ^ „
Showing Caecum and Funnel-shaped Ter- the case of the small minal extremity of the ileum. {Sappey.)
intestine. It begins at l- division of tlie small intestine;
. . 2, Opening of the small intestine into the large
the termination of the bowel ; 3, Lower section of ileo-caecal valve ;
• 1 -J J + +u Upper section of ileo-caecal valve ; 5, Bundles
Ileum and ends at tne of muscle-fibre passing over from the small on
anus. It is largest at tot^e large bowel ; 6, Lower section of caecum ;
o 7, Appendix vermiformis; 8, Posterior outer
the caecum and gradu- t^^^ia; 9, Posterior inner taenia; 10, Anterior
° taenia; 11, Haustra {Sacmli).
ally diminishes in cali- bre until the rectum is reached, where there is again an increase in size. The large bowel in its course describes an arch in the concavity of which the loops of the small intestine are located. From the right iliac fossa, the point of beginning, it runs upward through the right lumbar and right hypochondriac regions to the under surface of the liver, where it makes a curve, which IS covered by the overlying liver; passes then trans-
The Large Bowel in Position. (Hartmann )
a, Ascending colon ; &, Transverse colon ; c, Sigmoid flexure ; cf, e, gr, Mesocolon and mesentery ; h. Fascia covering inner pelvic muscles. 1, Central tendon (of dia- phragm) ; 2, Opening for the ujsophagus ; 3, Bundles of muscle-libre of the under surface of the diaphragm ; 4, Appendix vermiformis.
8
ANATOMY OF THE INTESTINES
9
versely, with a somewhat upward tendency, onward be- tween the borders of the epigastric and umbilical regions into the left hypochondriac region, — near the spleen, about two vertebra higher than to the right, — where it again makes a curve and descends through the left lum- bar region and left iliac fossa, where it makes a sort of fold known as the sigmoid flexure ; it then passes down- ward and terminates at the anus. The large bowel is divided into various parts : the ccBcum and appendix vermi- formis, the ascending colon, the transverse colon, the descend- ing colon, the sigmoid flexure, the rectum; and the anus.
The caecum (blind pouch) is the largest segment of this section of the intestinal tract. It measures about two and a half inches both in its vertical and transverse diame- ters. It lies in the right iliac fossa on the right internal iliac muscle, with its end about the middle of Poupart's ligament. It is retained in position by the peritoneum, which passes over its anterior surface and sides, and posteriorly it is connected by loose areolar tissue with the iliac fossa. Occasionally it is almost surrounded with peritoneum, which then forms a mesocaBCum.
About the junction of the caBCum and the ascending colon the ileum opens into the large bowel by a narrow, elongated, slit-like, aperture at right angles to the axis of the bowel. The mucous membrane forms here two semilunar valvular folds which project into the bowel and constitute the ileo-caecal valve, the valvula Bauhini. At each end of the orifice the valves coalesce, and are continued as a narrow membranous ridge around the canal of the bowel for a little way, forming the frsena or retinacula of the valve. At the left extremity of the
10
CONSTIPATION IN ADULTS
slit the aperture is rounded ; at the right end it is narrow and pomted. When the caecum is distended, the borders of the valvular folds are closely approximated and any reflux prevented.
At the lower and posterior portion of the caecum, there is found attached a small worm-like process, the appendix
iiEo - Colic feio
tieuM
ORIPICE of APPtNDlX Vermiformis
(From Harrison Alleu's Human Anatomy.)
vermiformis. It is from three to six inches in length ; exceptionally it may be found longer ; thus Luschka saw one that had a length of twenty-three centimetres (about eighteen inches). Its diameter is about the size of a goose- quill. It opens into the caecum by a minute orifice at which an incomplete valve-like projection of the mucous membrane is sometimes found.
The Ascending Colon : that part of the large intestine
ANATOMY OF THE INTESTINES
11
lying on the right side of the abdomen between the crest of the ilium and the diaphragm. Continuous with the C£ecum and smaller than it, it mounts upward and some- what outward, to the right hypochondrium, passing in front of the lower half of the right kidney. Here it makes a turn, the jlexura coli dextra seit lieioatica, runs horizontally and to the left, and terminates in the trans- verse colon.
The right colic flexure is in contact with the lower border of the right lobe of the liver and partly also with the gall bladder.
The ascending colon is covered anteriorly and on its sides with peritoneum and sometimes is completely invested by it, so that a narrow mesocolon is formed ; posteriorly it is usually covered by loose areolar tissue which connects it with the quadratus lumborum muscle and the kidney. It is thus retained in position.
The Transverse Colon : the longest part of the large bowel passes transversely across the abdomen between the lower boundary of the epigastric and the upper boundary of the umbilical region to the left hypochon- drium, where it makes a turn, the flexura coli sinistra seic linealis, and passes downward to terminate in the de- scending colon. In its passage across the abdomen it describes somewhat of an arch, the concavity being directed backward toward the vertebral column. This is known as the transverse arc/i of the colon.
This is the most movable part of the colon; it is almost completely invested with peritoneum and is attached to the vertebral column by a large and wide duplicature of this membrane, the transverse mesocolon.
12
CONSTIPATION IN ADULTS
It is in relation by its upper surface with the lower border of the right lobe of the liver, with the gall bladder, with the greater curvature of the stomach, and with the lower border of the spleen ; by its under surface with the small intestines; by its anterior surface with the great omentum and the other constituent parts of the abdominal parietes.
The Descending Colon passes downward through the left hypochondrium and the left lumbar region to the upper part of the left iliac fossa where it enters into the sigmoid flexure.
The Sigmoid Flexure. — This is normally the narrowest portion of the large bowel and lies in the left iliac fossa.
As usually described, the gut makes a double turn upon itself; begin- ning at the termination of the /xs^ descending colon it curves % \ Lt upward, then descends and iiiiijj. \ again makes an upward II. curve, the whole having the shape of the figure " § " — whence the name — and terminates in the rectum. According to Treves, however, this description, though classic, is erroneous; the flexure does not resemble the " § " Roma- num ; it has rather the figure of an omega — " Xl." He describes it as follows: "The descending colon ends just at the outer border of the psoas. The gut here suddenly changes its direction ; it crosses the muscle at right angles and about
(From Treves' Anatomy of the Intestinal Canal, etc.)
C, Usual shape of the un- folded loop (adult) ; M, Ter- mination of descebding colon; N, at the point of ending of the mesorectum.
ANATOMY OF THE INTESTINES
13
midway between the lumbo-sacral eminence and Poupart's ligament. It now descends vertically along the left pelvic wall and may at once reach the pelvic floor. It then passes more or less horizontally and transversely across the pelvis from left to right and commonly comes into con- tact with the right pelvic wall. At this point it is bent upon itself, and, passing once more to the left, reaches the middle line and descends to the anus." Treves includes in his description of the flexure what is usually denominated the first segment of the rectum. The aver-
A B
A, Most usual arrangement of the B, Rarer form of arrangement,
loop when in situ.
age length of this portion of the bowel in the adult is about 17 h inches. It is kept in place by a fold of peri- toneum,— the sigmoid mesocolon. The fold, however, is ample and permits of extensive movement on the part of this segment of the large bowel.
The Rectum. — This is the terminal portion of the. large bowel. It is narrower at its upper part than the sigmoid flexure, but dilates as it descends and, just before the anus, forms an ampulla, which may reach great size. The rectum, which varies in length from six to eight inches, is usually divided into three parts, — the upper.
14
CONSTIPATION IN ADULTS
the middle, and the lower portion. (As already stated, Treves recognizes but two segments, counting the first as part of the sigmoid flexure.) It begins at the left sacro- iliac symphysis, passes obliquely downward from left to right to the middle of the sacrum, making a gentle curve to the right. It regains the middle at this point and de- scends to the lower part of the sacrum and coccyx ; near the extremity of the latter bone it inclines backward to terminate at the anus, a buttonhole orifice, situated a little in front of the coccyx. The upper part of the rectum is completely surrounded by peritoneum and connected with the sacrum behind by a fold of this mem- brane, which is known as the mesorectum. In front it is separated, in the male from the posterior surface of the bladder, and in the female from the posterior surface of the uterus and its appendages, by some convolutions of the small intestines. The middle portion is closely con- nected with the sacriim ; it is covered by peritoneum on its upper and anterior portions only.
The Sphincters of the Anus. Hie external sphincter. — Like all sphincters, its purpose is to keep an orifice, that of the anus, closed. It consists of planes of muscular fibre which surround the anus. It is elliptical in shape and intimately adherent to the integument about the margin of the anus. It arises from the tip of the coccyx, and is inserted into the tendinous centre of the perineum, merging with the transverse perinei muscle. It has both voluntary and involuntary muscular fibres.
The internal sphincter is a plane of involuntary muscular fibres about one-half an inch in length, which
ANATOMY OF THE INTESTINES
15
surrounds the lower part of the rectum about an inch above the margin of the anus. A third sphincter does not exist.^
a
The External Sphincter of the Anus (and the Perineal Muscles in the
Adult Male). {Hartmann.)
1, The glutaeus maximus; 2, Same, divided; 3, Deeper fasciculi of the same; 4, Levator ani ; 5, 6, 7, Transversus perinei ; 8, Ischio-cavernosus ; 9, Bulbo-caverno- sus ; 10, External sphincter of the anus, a, Sacrum covered by its connective tissue ; h, Fascia ; c. Point of origin of the muscles of the thigh. *, The latter shown to the right covered with fascia, m, Ligam. anococcygeum.
Certain points in the structure of the large intestine are deserving of consideration.
It strikes the eye of the beholder at once that the
^ See Kelsey, Diseases of the Rectum and Anus.
16
CONSTIPATION IN ADULTS
large bowel does not present the smooth, even surfaces noted in the small intestine, but has a sacculated ap- pearance. This is due to the arrangement of the longitudinal muscular fibres in three large bands, from the beginning of the caecum at the appendix vermi- formis to the rectum. One of these bands, or taenige, is posterior along the attached border of the bowel ; the anterior, the largest, is on the forward surface of the ascending and descending colon and sigmoid flexure, and on the under surface of the arch of the colon. The third, or inferior lateral band, is found on the inner surface of the descending and ascending colon, and on the under surface of the transverse section. These bands, being shorter than the rest of the intestine, draw it together, and so produce the appearance described. When they are dissected off, the bowel can be drawn out and its sacculation disappears.
The mucous membrane, which is quite smooth and without villi, is thrown into crescentic folds, Plicci} Sigmoideoi, which project forward like valves between the sacculi. Their arrangement is such that their free borders are not all in the same direction.^
The rectum is not sacculated, but smooth and cylin- drical, the tsenige being wanting here. The mucous membrane of the rectum is thicker, more vascular, of darker color, and but loosely connected with the muscular coat. When the rectum is collapsed, its mucous mem- brane is thrown into folds which are in apposition with each other, and obliterate, as it were, the lumen of the bowel . When the rectum is distended, the folds disappear.
1 See chapter "Physiology of Peristalsis."
ANATOMY OF THE INTESTINES
17
Houston described as valves of the rectum folds of the mucous membrane found protruding into it, and ascribed to them the function of holding up the faeces, i.e. preventing its constant descent, and consequently constant irritation of the sphincter. They were said to be present in all persons, but to vary in number and location. It has, however, been disputed, and the weight of authority is against their existence, as a rule. This much, however, is positive, that even where such pro- truding folds do exist they have no valvular function; the rectum has no need of valves. Occasionally a large fold of mucous membrane is found, extending into the lumen of the tube; Kohlrausch described such a fold, which he calls lolica transversalis recti, and it has been seen by others.
About the level of the internal sphincter five or six little semilunar valves are noted, with their con- cavities directed upward toward the colon. ^ They form an irregular line around the canal. They are thus described by Dr. Horner : " The mucous coat of the rectum is thick, red, and fungous, and abounds in rau- cous lacunaB and glands. It is laid smoothly above, and below it is thrown into superficial longitudinal iolds called columns. At the lower end of the wrinkles between the columns are small pouches from two to four lines in depth, the orifices of which point upward ; they are occasionally the seat of disease, and produce, when they are enlarged, a painful itchifig."^
1 Handy, W. R., Text-book of Human Anatomy, Pliiladelphia, 1854.
2 Special Anatomy and Histology. Eighth Edition, Vol. II. Phila. 1857. Bodenhammer, "Observations on the Normal Sacculi of the Anal Canal," etc., Medical Record, May 26, 1888.
18 CONSTIPATION IN ADULTS
The function of these little pouches, Sacculi Homeric is apparently to collect mucus which may be required to lubricate the moving faeces, and thus facilitate its expulsion.
(From Handy, Text-book of Human Anatomy.)
Represents a section of the anus and rectum, showing the rectal pouches. aa, Columns of the rectum ; bb, Rudiments of columns ; c. Internal sphincter divided ; d, External sphincter divided ; ee, Folds of skin on the nates; /, Pouches ; g, Bristles in the pouches.
Arteries.
I. Pancreatico-Duodenalis, branch of the gastro- duodenalis, branch of the hepatic, branch of the cceliac axis, supplies the first part of the duo- denum.
II. Superior Mesenteric Artery : a large vessel aris- ing from the abdominal aorta a little below the cceliac axis. It passes forward between the pan- creas and transverse portion of the duodenum and descends between the layers of the mesentery to the right iliac fossa, where it terminates, con- siderably diminished in size. It supplies the
ANATOMY OF THE INTESTINES
19
whole length of the small intestine except the first part of the duodenum. It also supplies the csecum, ascending and transverse colon.
Branches: Vasa intestini tenuis, fifteen or twenty branches, arising from the convex side of the artery. They anastomose with each other in a series of arches which become smaller and more numerous as they approach the small in- testines, to which they are finally distributed.
Inferior pancreatico-duodenal is distributed to the transverse and descending portion of the duo- denum ; it anastomoses with the pancreatico- duodenalis.
Ileo-coUc, distributed to the lower portion of the ileum, caecum, and vermiform appendix. Anas- tomoses with branches from the inferior mesen- teric artery.
Colica dextra to the ascending colon.
Colica media to the transverse colon. The artery is accompanied in its course by the superior mesenteric vein, and is surrounded by the superior mesenteric plexus of the sympathetic nervous system. III. Inferior Mesenteric Artery arises from the left side of the abdominal aorta just before the point of bifurcation. It is not so large a vessel as the superior mesenteric artery. It supplies the descending colon, the sigmoid flexure, and the greater part of the rectum.
Branches : Colica sinistra to the descending colon.
Arteria sirjmoidea to the sigmoid flexure.
20
CONSTIPATION IN ADULTS
IV. HyEMORRHOiDALis SUPERIOR is the Continuation of the inferior mesenteric artery from the iliac fossa downward. It descends between the meso- rectum to the rectum, and at about its mid- dle divides into two branches which descend on either side of the rectum, where they divide into several smaller branches, which are dis- tributed to the muscular and mucous coat of this section of the bowel near its lower end. These anastomose with each other, with the middle hsemorrhoidal and inferior hsemorrhoidal arteries, and with branches from the internal iliac and internal pudic arteries. This artery is accompanied by the inferior mesenteric vein, and is surrounded by the inferior mesenteric plexus of the sympathetic nervous system. V. Middle Hemorrhoidal Arteries. Branches of the internal iliac, distributed to the anterior part of the rectum. VI. External Hemorrhoidal Arteries. Two or three small arteries — branches of the internal pudic, distributed to the muscles and integu- ment about the anus. Veins. — Superior mesenteric vein.
Inferior mesenteric vein, unite with others to
form the ijortal vein.
Nerves of the Intestinal Tract. — The nervous system of the intestinal tract is almost altogether part of the great sympathetic system. The nerve filaments and
ANATOMY OF THE INTESTINES
21
Ret.
Diagram to illustrate the Nerves of the Alimentary Canal in the Dog.
Foster, Human Physiology.
The figure is for the sake of simplicity made as diagrammatic as possible, aiid does not represent the anatomical relations.
Oe to Ret. — The alimentary canal, oesophagus, stomach, small intestine, large intes- tine, rectum.
L. V. Left vagus nerve ending on front of stomach, r.l. recurrent laryngeal nerve supplying upper part of oesophagus. R. V. right vagus, joining left vagus in ojsophageal plexus, oe. pi., supplying the posterior part of stomach and con- tinued as R' .V . to join the solar plexus, here represented by a sinc/le c/anglion and connected with the inferior mesenteric ganglion (or plexus) m. gl. — a. branches from the solar plexus to stomach and small intestine, and from the mesenteric ganglion to the large intestine.
Spl. maj. Large splanchnic nerve arising from the thoracic ganglia and rami com municantes r.c. belonging to dorsal nerves from the (ith to the {)th (or 10th).
Spl. mill. Small splanchnic nerve similarly arising from 10th and 11th dorsal nerves. These both join the solar plexus and thence make their way to the alimentary canal.
C.r. Nerves from the ganglia, etc., belonging to 11th and 12th dorsal and 1st and 2nd lumbar nerves, proceeding to the inferior mesenteric ganglia (or plexus) m. gl. and thence by the hypogastric nerve n. hyp. and the hypogastric plexus pi. hyp. to the circular muscles of the rectum.
l.r. Nerves from the 2nd and 3rd sacral nerves, S.2, S.3 (nervi erigentes), proceeding by the hypogastric plexus to the longitudinal muscles of the rectum.
22
CONSTIPATION IN ADULTS
plexuses are derived more directly from the following plexuses, which are themselves but part of the great solar, or epigastric, plexus :
The superior mesenteric plexus, The inferior mesenteric plexus, The aortic plexus. The hypogastric plexus.
The superior mesenteric plexus accompanies the su- perior mesenteric artery into the mesentery, and there divides into a number of plexuses which follow the branches of the artery to the parts supplied by it; namely, the small intestines, the caecum, the ascending and the transverse colon.
The inferior mesenteric plexus (which originates more directly from the aortic plexus) accompanies the rami- fications of the inferior mesenteric artery to the parts supplied by it, — the descending colon and the sigmoid flexure.
The superior hoemorrhoidal plexus (which also is part of the aortic plexus) supplies with nerve filaments the upper part of the rectum.
The inferior hcemorrhoidal plexus, part of the hypo- gastric plexus, distributes itself over the inferior portion of the rectum and there unites with the ramifications of the superior hsemorrhoidal plexus.
These plexuses, after they have entered into the intestinal structure, divide into two distinct layers, which surround the intestinal tissues in every direction. The first layer is located between the longitudinal and the circular layers of muscular fibres, and constitutes the
ANATOMY OF THE INTESTINES
23
plexus myentericus of Auerhach. The second layer is found between the mucous membrane and the sub- mucous tissue, and is the plexus of Meissner. These plexuses are formed by a network of fine non-medullated nerve fibres, with ganglia and ganglionic cells located at various points in the network. There are communi- cating branches between the two layers.
Plexus of Auerbach, between the Two Layers of the Muscular Coat of
THE Intestine. {Cadiat.)
The bowels have no direct connection with the cerebro- spinal system ; indirectly, however, they have such con- nection. As has been said, all the various plexuses above recounted are more or less part of the great solar plexus, and this receives the terminal extremity of the right pneumogastric nerve.
Through the solar plexus the intestines are in com- munication with the various organs of the body ; for,
24
CONSTIPATION IN ADULTS
besides the terminal portion of the right vagus nerve, this plexus receives also the ends of the splanchnic nerves, the greater and the lesser, which are derived
from the thoracic sympathetic gan- glia.
Only the rectum and the anus are in direct communica- tion with the cere- brospinal system. Besides the branches of the great sym- pathetic system al- ready named, these parts receive nerve •filaments from the sacral plexus of the spinal cord. The part, however, that is most abundantly
Plexus of Meissner from the Submucous Coat Supplied witll llCrves OF THE Intestine. (Cadiat.) c ,-, ,
irom the cerebro-
a, Cavity of tubular glauds or crypts; h, one of the lining epithelial cells ; c, Interglandular tissue ; d, Lym- Spinal Systcm, is the phatics. , , .
external sphincter.
1. The inferior hcemorrhoidal nerve (usually a branch of the pudic) is distributed to the external sphincter and to the integument around the anus.
2. The posterior hranch of the superficial jyeriiieal nerve passes to the back part of the ischio-rectal fossa and distributes filaments to the sphincter ani and the integu-
ANATOMY OF THE INTESTINES
26
meiit around the anus: these unite with the inferior haemorrhoidal nerve.
Moreover, the integument around the anus with which
Bulbo-cavernosus
Superficial triangular ligament Ischio-cavernosus
Gluteous Maximus
Tuberosity of Ischium
Sacro-sciatic ligament
Levator ani
a 1. • Snnerficial transverse perinei Spnincter am ' '
The Malf. Perineum. (From Morri.s' Text-book of Human Anatomy.)
1, Inferior pudendal nerve; 2, Superficial perine<al nerve; 3, Inferior hiBmorrlioidal nerve; 4, Cutaneous branch of fourth sacral.
the sphincter is in intimate relation, and the accessory muscles of the latter, receive filaments from various branches of the great sacral plexus, the cutaneous from
26
CONSTIPATION IN ADULTS
the fourth sacral, the inferior jmdendal, and the anterior branches of the superficial permeal.
The bowels hang rather loosely attached to various parts in the abdominal cavity. They are supported and kept in place by the muscles and other structures form- ing the anterior and the posterior abdominal walls.
LuscHKA. Die Bauchorgane des Menschen. Gkay. Anatomy — Descriptive and Surgical.
Treves. The Anatomy of the Intestinal Canal and Peritoneum.
Hunterian Lectures. Klein, E. Atlas of Histology. Elements of Histology. Mathews. The Diseases of the Eectum, etc. Kelsey. Diseases of the Eectum and Anus. Houston. Dublin Hospital Keports, 1830 (Vol. V.). KoHLRAuscH. Anat. et Physiolog. der Beckenorgane. Leipzig,
1854.
CHAPTER II
FLATUS (HNEYSIS, WIND, GAS)
In the course of the process of digestion in the intes- tinal tract, by reason of the breaking up of the various alimentary matters ingested and their elaboration into assimilable material, gases are developed in the stomach and in the intestines. They were primitively divided by Van Helmont ^ into two groups, — the inflammable and the non-inflammable, the gases of the large bowel consti- tuting the former, those of the stomach and the small intestines the latter group. This same subdivision was adopted by Priestley.
The flatus thus formed is constituted by various gases : carbonic acid gas (CO.2, carbon dioxide) ; carburetted hydrogen (CH4, methane, marsh gas) ; nitrogen (N) ; hydrogen (H) ; sulphuretted hydrogen (HgS [HSg], hydro- gen sidphide). The last is found normally in the intestines only.^ There is some difference of opinion in regard to carburetted hydrogen, whether it is a normal constituent of the flatus or not.-
1 Tract, de Flatibus, 27.
2 In pathological conditions of the stomach, in dilatation with decided stagnation, it is also found in the stomach and readily recognized in the withdrawn stomach contents by the well-known test.
3 Planer, Siizungsherichte d. Akadem. d. Wissenschaften zu Wien, Vol. XLII. Ruge, Ibid. Vol. XLIV. 734. Chemisch. Centralhlatt, 1862, 347. Nowack und Brautigam, Muenchener Mediz. Wochensclir. 1890.
27
28
CONSTIPATION IN ADULTS
The gases vary of course in volume, depending much upon the cliaracter of the food that is taken. Thus it IS well known that the leguminous seeds, as peas and beans, give rise to a greater proportion of flatus, espe- cially of carburetted hydrogen, than do other articles of food.
In addition to the gases thus developed, a certain amount of the volume of the flatus is derived from extra- neous sources ; a certain amount of air is swallowed with the food in the act of deglutition and a quantity of car- bonic acid gas (perhaps the greater part) is diffused into the intestines from the blood-vessels.^
The following table of Planer gives the volumes of the various gases as found by him in the stomach, in the small intestines, and in the large bowel:
|
Gases, in Volume, Per Cent. |
1 1 Stomach. |
Small Intestines. |
Lauge Bowel. |
|||
|
CO2 |
20.79 |
38.83 |
16.23 |
32.27 |
30.64 |
34.80 |
|
H |
6.71 |
27.58 |
4.04 |
35.55 |
||
|
CH4 |
12.88 |
|||||
|
N |
75.50 |
38.22 |
79.73 |
31.63 |
69.36 |
50.20 |
|
0 |
0.37 |
0.05 |
||||
|
SH2 |
Trace |
Trace^ |
Ruge'^ found the flatus of the large bowel collected per anum, regard having been had to the influence of diet, constituted as follows :
1 Foster, Physiology. Landois and Sterling, Physiology. Charles, S. J.,
Rrilhh Medical Journal, 1885, February, "The Sources, etc., of Carbonic Acid."'
•2 I pit, « Loc. cit. Foster, Physiology.
FLATUS (HNEYSIS, WIND, GAS) 29
|
Mixed Diet. |
Leguminous Diet. |
Meat Diet. |
|
|
40.54 |
21.05 |
8.45 |
|
|
17.50 |
18.96 |
64.41 |
|
|
19.77 |
55.94 |
26.45 |
|
|
22.22 |
5.03 |
0.69 |
|
|
SH, |
Trace only |
The flatus is an important factor in the proper func- tioning of the bowels ; it stimulates peristalsis, tends to keep the intestines distended, and contributes much to the looseness of the ingesta and of the faecal matter.^
Under normal conditions the flatus is removed from the intestines bj reabsorption by the blood-vessels, and by discharge through the rectum.
When from any reason this disposition of the flatus is interfered with, it accumulates, augments in volume, distends the belly, and not infrequently is the cause of spasmodic pains, more or less severe, therein.
Its presence in larger volume is recognized by the char- acteristic tympanitic sound given forth by the abdomen upon percussion. The accumulation of flatus in habitual constipation, where it is mainly confined to the large bowel, is never so great as in the acute forms of constipation,^ where both accumulation and exaggerated formation with greater distension of volume are favored. Occasionally the flatus may itself become the cause of a constipation.
When fgecal vomiting occurs, the abnormal accmnu- lation and production of flatus is the chief factor thereof.
^ Nowack and Brautigani, loc. cit..
2 The conditions favoring the free development and action of the patlio- genic bacteria.
CHAPTER III
mTESTINAL PERISTALSIS
Just as they differ in anatomical appearance, so do the two sections of the intestinal tract differ in function. Whilst it is the province of the small intestines to elaborate the chyme coming from the stomach and such other parts of the food taken as have as yet undergone but little change into substances that can be readily assimilated by the system, and to absorb these from the moving mass of matter as it progresses on its downward journey, the large bowel collects the indi- gestible residue, and after extracting what little of nutri- tive material remained therein, propels it onward and downward and expels it from the body.
In the performance of its functions the intestinal tract makes a series of movements, known as peristalsis {irepLCTTeWa), to send around, to surround), by which the food materials are carried onward and downward. These movements are vermicular in character, and are produced by the contractions of the several layers of muscular fibres clothing the intestines. There is a con- traction of the circular muscular coat which travels lengthwise and downward; following it, a contraction of the longitudinal muscular fibres, which also travels lengthwise and downward. The circular layer of mnscu-
30
INTESTINAL PERISTALSIS
31
lar fibres being the largest, its contractions are the most powerful and the most effective. By them the lumen of the tube is constricted at that particular point and an upward escape of the contents prevented ; at the same time a pushing downward force is exerted. The contrac- tion of the longitudinal fibres shortens the special section of the intestine, and thus materially aids the forward and downward transport.
Small Intestines. — The peristaltic action of the small intestines begins at the duodenum. It is not a continuous movement, i.e. that, beginning at the duodenum, it con- tinues onward in regular course without interruption until it has reached the ileo-ctecal valve. It continues for a short distance, and beyond that for another distance everything is quiescent ; beyond that again, activity. Frequently several distinct sections or loops, lying side by side, are contemporaneously in action, with perfectly quiescent portions or loops intervening between them. All at once the active sections will become quiescent, whilst the previously immobile parts will become active.^
The peristaltic movements of the small intestines can, according to Nothnagel,^ be divided into two groups : the first, already described, the vermicular action, alternate contraction and dilatation and lengthening and shorten- ing of the tube. With this a change of position of the active loop or loops may occur, making a sort of rolling motion. The second, observed in the small intestines only, is a to-and-fro, pendulum-like movement. It is til ought that by this motion the various constituents
1 Nothnagel, Beitriige zur Physiologie u. Pathologie des Darmes. Ibid.
Il
32
CONSTIPATION IN ADULTS
of the chymus are more thoroughly shaken together, and, furthermore, the chyme, which is acid,^ is brought into more immediate contact with the secretions of the intes- tinal parietes, which are alkaline.^
This is the more plausible, as during this special movement there is no carrying forward of intestinal contents, they remaining in the parts in motion even though this continue for quite a length of time.
This oscillatory movement is produced more particu- larly by the action of the longitudinal muscular fibres.^
The movements of the small intestines are slow.
Large Intestines. — Almost all that is convertible into assimilable material having been properly prepared and almost altogether absorbed, the indigestible residue is discharged into the large bowel, into the caecum. Here putrefactive changes, brought about by apparently a specific microbe,* take hold of the residue of the albu- minous matter that has passed over and it is broken up into its ultimate products, — indol, skatol, etc. Here also what little of assimilable material has been carried over is absorbed. Then by peristaltic action, which is the same as in the small intestines, the residuum is pushed gradually onward from sacculus to sacculus, assuming more and more the color, form, and consistence of normal fseces, until, when it arrives at the sigmoid flexure, it is the fa3ces ready for expulsion.
1 Macfadyen, Nencki, and Sieber, Archiv f. experiment. Pathologie a. Pharmacologie, Vol. 28, Heft 1 and 2.
2 Ibid.
8 Foster, Phy.siologv.
4 Bienstock, Zeilschrift f. klin. Medizin, 1884. Macfadyen, Nencki, and Sieber, loc. cit.
INTESTINAL PERISTALSIS
33
The peristaltic movements in the large bowel are much slower than in the small intestines.
The time occupied in the passage of the small intestines is three to four hours; of the large bowel, from ileo- cecal valve to rectum, it is twelve hours.
As to the causes producing these movements, this much can be said: An impulse to movement is undoubtedly communicated by the pyloric portion of the stomach, and by the chyme projected into it, to the duodenum. That the chyme does per se excite peristaltic action has been established by Nothnagel.^ The discharge of the bile adds to the impulse. Then the acid chyme coming in contact with the alkaline secretions of the intestinal walls and with the various other secretions poured into the intestinal canal, chemical changes are instituted and gases developed, which also, as has been experimentally observed, have a stimulating effect on the bowel. In addition to all this, we have the influence of the coarse particles in the chyme. In the large bowel, though un- doubtedly a certain amount of impulse or stimulus is received from the smaller intestine, still the principal factor of the peristalsis here are the coarse j^oLrticles of the indigestible residue.
It has been a question with physiologists, and one that is not yet definitely settled : Is the peristalsis due to nervous action or is it the result of muscular irritation ? It is possible that the peristalsis is entirely due to muscu- lar irritability, i.e. that the irritation of the mucous mem- brane is communicated to the underlying cell of the muscular coat, and thence passed from one cell to
1 Loc. cit.
34
CONSTIPATION IN ADULTS
another; experimental study and clinical observation, however, indicate clearly that it is the result of nervous action.^
This view is certainly more in harmony with physio- logical processes ui other parts of the body, and is more than confirmed by the abundant nerve supply furnished the intestines by the great sympathetic system as already described.
The cerebrospinal system is ordinarily not interested in this peristalsis. It always proceeds without any percep- tion thereof on the part of the cerebrum ; only when it becomes abnormal, when it becomes spasmodic, either from excess of local irritation or by reason of an irritant impulse that has been sent down from the cerebrum through the vagus, do we become conscious, painfully so, of the movements going on within us.
Upon the basis here set forth there are no contradic- tions, and the rather varied clinical phenomena observed, such as the production of diarrhoea by sudden mental shock or impression, are readily explained.
From the results of various experimental observations it has been assumed that the sudden stoppage of the circulation would produce increased peristaltic action, and that this was directly due to the carbonic acid which accumulated in the blood. However, the investigations of Van Braam Houckgeest ^ and of Nasse ^ have shown that just the reverse is true ; venous stasis and accumula- tion of CO2 have an inhibitory influence, arrest peristalsis,
1 Nothnagel, loc. cit.
2 Pflueger's Archiv, Vol. VI., 1872.
» Beitrage z. Physiolog. d. Darmbewegungen, 1866. Foster, Physiology.
INTESTINAL PERISTALSIS
35
whilst increased oxygenation makes the movements more 'powerful.
The gases developed in the intestinal tract, by keeping the bowels moderately distended, greatly facilitate the passage through them, from pylorus to rectum, of the chyme and residuary bolus. ^
Defecation. — As can be seen from the configuration of the sigmoid flexure, whether it be of the form described by anatomists generally or it have the shape noted by Treves (upon careful reading of his description and atten- tive inspection of his drawings, it does not require a great stretch of the imagination to see an "s" romanum [rather a sigma] in the omega), it is evidently intended for the accumulation of faeces ; and this is truly its purpose. The fully formed faeces accumulate in the flexure and are held there ready to be discharged. Ac- cording to the description of O'Beirne,^ there is a narrow- ing at the point of junction of the sigmoid flexure and the rectum — O'Beirne's sphincter. But even if this be disputed, it is nevertheless readily understood how the faeces can collect therein. As already stated, the move- ments of the large bowel are very slow, and there is but little vis a tergo. The sigmoid flexure is of large capacity ; moreover, lying as it does on the sacrum* and bladder, it is supported, held up, and the faeces kept from falling down. The rectum is always free from faeces, as was stated by O'Beirne, and as I have amply convinced myself. Its walls lie ordinarily in apposition and it thus forms an additional support for the faecal masses gathered
1 See Chapter II. New Views on the Process of Defecation, etc., 1834.
36
CONSTIPATION IN ADULTS
in the flexure. The pouch frequently forms an exception to the rest of the rectum, in that it may contain some faeces, whilst the balance of the " straight tube " is empty.
The mius, the terminal extremity of the intestinal tract, . is guarded by the external sphincter, which is habitually in a state of tonic contraction, which can be increased or diminished by a stimulus applied to it, either internally or externally.
This contraction is perhaps altogether due to the action of a special nerve centre, situated in the spinal cord. Experimental investigation has shown that this centre is not situated higher than the lumbar region of the cord. Increased irritability or diminution of the same in this centre is followed by increased or diminished contraction of the sphincter. This centre is again under the control of the higher centres in the brain. By the action of the will, by emotions, the centre may be inhibited and a relaxation of the sphincter result, or its irritability may be heightened and the sphincter become more firmly contracted. The sphincter can be acted upon directly by the cerebrum and a strong contraction thereof effected. However, under circumstances, the energetic peristalsis may overcome all efforts of the will. Irritation of the pedunculus cerebri and downward along the spinal cord produces a contraction of the exter- nal sphincter.'
As long as the faeces remain above the rectum, no perceptible sensations are conveyed to our mind. As soon, however, as the fceces pass into the rectum and reach about the middle thereof, an irritation of the nerve
1 Landois, Lehrbuch der Physiologie des Menscheii, 1880.
INTESTINAL PERISTALSIS
37
filaments traversing the mucous membrane is set up, — a notification, as it were, is sent to us; we become con- scious of its presence whilst at the same time the sphincter is more firmly contracted.
The process of defecation would therefore be about as follows : The peristalsis in the large bowel becomes more energetic, a quantity of feeces descends into the rectum pushed onward by the vis a tergo of the moving masses, a notification is at once sent in, whilst the sphincter becomes firmly contracted. Ready for the evacuation, by the command of the will (automatically, according to some), the sphincter centre in the cord is inhibited and a relaxation of the muscle results. The sudden emptying of the rectum creates a vacuum, the air rushes in, the rectum is kept open, and faeces from the flexure follow.
There is a further and more powerful factor concerned in this process ; namely, the voluntary, forcible drawing in of the wall of the abdomen, — the abdominal pressure (Bauchpresse) which we call in to aid the involuntary mechanism hitherto considered. An inspiratory act is begun, the lungs are moderately filled, then the glottis is closed ; the diaphragm is in the inspiratory position, i.e. descended, and the abdominal walls are strongly drawn in. By this means we exert a powerful pressure upon all the abdominal organs, upon all parts of the colon ; its contents are pressed out, as it were, pushed into the flexure, and that which had been previously stored there made to descend into the rectum. Even if we are inclined to hold that the sigmoid flexure is removed from the influence of the pressure exercised by the abdominal walls (which I doubt very much), the
38
CONSTIPATION IN ADULTS
expression of the other parts of the colon, the increased peristalsis naturally excited, and the dilatation of the rectum by the inrushing air are amply sufficient to effect a further descent of the faBces.
This pressure with the abdominal walls can be exercised with greater or less force, according to the needs of the hour. Greater force is, of course, demanded if the peri- stalsis be slow, feeble ; if the tonicity of the intestine be impaired ; if the faeces be hard and dry, either from over inspissation or from a lack of sufficient mucous secretion ; much less force, when all things are normal.
By the movements described the perineum is pressed out, the anus is dilated, and the sharp bend in the lower part of the rectum somewhat straightened, and this part brought more into line with the rest of the canal. The levator ani muscle, which forms a support for the pelvic organs during the act of straining, assists also in the act of defecation; by its contraction it draws the anus and the marginal extremity of the rectum upward, strips it, as it were, over the descending column of faeces, and thus hastens its discharge. It also aids in retracting the soft parts that have been pushed out in straining.^
1 Flint, A Text-book of Human Physiology, 1888. Landois, Lehrbuch der Physiologie des Menschen. Carpenter, Human Physiology. Foster, M., A Text-book of Human Physiology, 1891.
CHAPTER IV
A NORMAL omnivorous individual discharges from four to six ounces of faeces in the twenty-four hours. The quantity varies with the quantity of food that is taken, being larger in gross eaters. It varies also with the character of the food that is taken. A diet of which vegetables form the major part will, naturally, give a larger quantity of faeces than one which is almost entirely made up of nitrogenous substances. These latter are taken up almost altogether into the system, leaving but little detritus.
Of the quantity thus discharged, seventy-four per cent is water, and twenty-six per cent solid constituents. This proportion is requisite for the natural and easy discharge of the excrement. When the proportion of water falls below fifty per cent, then the matter is moved with greater difficulty, and consequently much more slowly, to the outlet ; whilst should it fall below twenty per cent it cannot be moved at all, even with the muscular power of the intestine at the normal, and accumulation results.
Ordinarily the f£eces are a homogeneous mass of fair consistence and of sausage-like shape. The consistency, like the quantity, depends upon the food that is taken ; it is firmer with an abundant meat diet, whilst it is
39
40
CONSTIPATION IN ADULTS
more like pap when vegetables form the main article of .sustenance.
The color is usually a yellowish or dark brown, and is due chiefly to biliary pigment. This also varies some- what with the character of the diet. A milk diet gives a light yellow stool. Certain articles of food, rich in coloring matters, may give it an unusual coloration.
The odor is characteristic, and is the result of the putrefactive processes that go on normally in the large bowel as described.
The reaction, though generally alkaline, varies also with the diet. With vegetarians, or with those who live mainly on vegetable food, it is acid ; with a meat diet, or with the average admixture of nutritive material, it is alkaline.
The faeces consist of residuary indigestible matters, of the products of destructive cell metamorphosis and of chemical change, and of substances gathered up in the intestinal tract. The extraneous matters are plant cells, vegetable fibre, starch grains, muscle fibre, connective tissue, and fat. From the intestinal tract there are gathered up epithelium, round cells, mucus, and bacteria ; bile salts and bile pigment. In addition, they contain crystalline salts, the products of the digestive process: the ammonia-magnesium phosphate, neutral phosphate of lime, lime salts colored yellow by bile pigment, and oxalate of lime.
Mucine is a regular constituent of the faeces. Albumen is never found.
A microscopical examination of the fjEces is always advantageous and is readily made. A minute quantity
F^CES
41
of fiBces is rubbed up on a slide, — if it be too dry a drop of water can be added, — covered with a cover glass and put under the microscope. Normal faeces from the ordinary mixed diet will present a picture like this :
Normal FiscES. (From Jaksch, Klinische Diagnostik.)
a, Muscle fibres ; b, Connective tissue ; c, Epithelium ; d, White blood-corpuscles ; e, Spiral cell (vegetable cell); f-i (inclusive) vegetable cells of diverse forms; k, Triple-phosphate crystal ; between these various elements an enormous mass of micro-organisms; I, Diatoms.
In the stools of persons living almost exclusively upon a meat diet bu^t very little or no vegetable residue, as plant cells or vegetable fibre, will be found.
Such an examination will disclose to us any foreign bodies that may be present as helminthes or the products of pathological processes going on in the intestine.^
1 Flint, Text-book of Human Physiology. Von Jaksch, Klinische Di- agnostik. Landois, Lehrbuch der Physiologie des Menschen. Rosenheim, Pathologie u. Therapie der Verdauungskrankheiten, Theil II.
CHAPTER V
DEFINITION; ETIOLOGY; CLASSIFICATION
Constipation — delayed evacuation of the bowels — is said by many to be but a comparative term, and what might be considered constipation in the one is normal habit in the other.^ They hold this for the reason that we see persons who have a stool but once in three or four days, a week, or even longer, in the enjoyment of good health, and I myself saw a woman who had but a limited evacuation once a month — every thirty days a midwife came to her house and scooped out the accumu- lated and hardened faecal masses from the rectum — and still she did not, apparently, suffer much from this reten- tion. Retarded evacuation can therefore, according to these authorities, be called constipation only when morbid symptoms manifest themselves concomitantly with it. I am, however, of a different opinion. It is the consensus of physiologists that every normal person should have an evacuation once in twenty-four hours, or, taking into con- sideration that our food at the present day is freer from coarse particles, and that therefore peristalsis is slower, at least once every other day.^ I, therefore, regard every person who does not have a full, free evacu-
1 Chambers, Digestion and its Derangements. Henoch, Unterleibski-ankh. Nouveau Dictionnaire de Mddecine et de Chirurgie pratique.
2 Flint, Landois, Foster (Physiology).
42
DEFINITION; ETIOLOGY; CLASSIFICATION
43
ation once in three days at the furthest, without, of course, the aid of extraneous measures, as constipated, even though he present no disturbances of normal function. It is possible that certain of the fluid or solid constituents of the body have suffered a change in some of their con- stituent elements, either by the addition of a foreign element or by the subtraction therefrom by chemical metamorphosis of a native one ; a change, however, which escapes our observation because our knowledge of the intimate normal constitution of these bodies is still far from complete, and our methods of examination and the mechanical aids thereto are still defective. Moreover, it cannot be maintained that in case of sickness from other causes in such a person, that the constipation will not make itself felt to the detriment of the patient. It can- not be maintained that the constipation does not render the person particularly prone to a certain category of ailments, or even predisposed to all the ailments that flesh is heir to. Even if the foregoing be disputed (which it cannot), it can only be said that a tolerance has been established ; that the system has become habituated to this state even as the mountaineers of Styria have become accustomed to arsenic, and such an individual can eat with gusto an amount of the drug that would, with us, suffice to send a regiment of soldiers to the bourne whence no traveller has as yet returned.
What is constipation? Constipation means that al- though a sufficient quantity of food is taken and digested fully, there is, nevertheless, a ivant of normal discharge of the indigestible residual matters and the other matters therein gathered iqj from the hoivel.
44
CONSTIPATION IN ADULTS
This definition excludes, and what I regard as very properly, the long-delayed defecation resembling consti- pation, which we find as one of the symptoms of
Stricture of the aesophagus, or obstruction of the same
by tumors from without; of Ulcer of the stomach ; of
Cancerous disease of the stomach about the pylorus ; of Non-malignant stricture of the pylorus ; of Ulcer of the duodenum.
In all these morbid states very little food is usually taken, or rather can be taken ; what is taken is of con- centrated nutritive form, with little or no residual matter, and even of that little which is ingested, a considerable portion is usually vomited. If much or coarse food is taken, it is certainly almost altogether rejected. It is very evident, therefore, that the condition is not one of con- stipation, but rather an absence of material to be dis- charged. For the same reason, I exclude the absence of alvine discharges in starvation, inanition, although some authors class it and describe it under the head of consti- pation.^
All classes and conditions of life are liable thereto. It is found in both sexes, and at all ages. It is a matter of common observation that females are much more prone to this derangement than males, for the reason that besides the causes common to both sexes, there are a number of etiological factors, special to them, as ailments, acute or chronic, of their generative organs, relaxation of their
1 Nouveau Dictionnaire de Medecine et de Chirurgie pratique, Jaccoud. Article "Constipation."
DEFINITION; ETIOLOGY; CLASSIFICATION 45
abdominal muscles, and the more stringent rules of
modern society.
It is not an uncommon condition in infants, and is fre- quently a source of more or less inconvenience to the aged.
The causes that lead to this condition are many ; they can be well grouped under the following four heads :
1. Pathological conditions, within or without the intes- tinal tract.
2. AbnormaHties of form, congenital or acquired, or dislocations of sections of the large bowel.
3. Foreign bodies in some portion of the bowel.
4. Defective performance of normal physiological function.
Although various divisions of the subject have been already made, I believe that for clinical purposes, con- stipation, in whatever way produced, is best divided into two great groups :
I. Acute Constipation. II. Chronic Constipation.
By acute constipation I understand that form which, coming on suddenly, is but one of a group of symptoms of a special, well-defined, and acute pathological process ; where, in the treatment of the case, our attention is not specially directed to the relief of the constipation, even though we may resort to laxative medication ; where with the cure of the pathological process the constipation disappears.
Chronic constipation embraces that form which is of slow and gradual development, and which does not present any acute morbid phenomena.
CHAPTER VI
ACUTE CONSTIPATION
Acute constipation is produced in various ways :
A. By direct ohsti^uction of the lumen of the intestinal tube. This occurs,
In Intussusception.
In Volvulus (twisting or torsion) of the rectum or sig- moid flexure (the parts where it more commonly occurs).
In Twisting or inversion of the caecum.
In Strangulation by the edges of some orifice, natural or artificial, into which a section of the small intestine may have dropped. Such orifices are the foramen of Winslow,^ perforations in the mesentery, meso- colon, great omentum, or other duplicatures of the peritoneum.
In Strangulated hernia.
In Obstruction by foreign bodies.
The foreign bodies found in the intestinal tract can be divided, according to their derivation, into two groups :
(a) Those introduced from without, (6) Those formed within the body.
1 Rokitanski, Patholog. Anatomy. . 40
ACUTE CONSTIPATION
47
(a) The group (a) can be again divided, according to the mode of introduction, into two subgroups :
1. Foreign bodies introduced by the mouth,
2. Foreign bodies introduced by the rectum.
1. The first of these subgroups is very well known to physi- cians, who are all more or less frequently consulted as regards thereto, especially in the cases of children, who seem to delight in the swallowing of extraneous matters. The bodies so intro- duced are varied in their nature : copper coins, pieces of silver, buttons, bones, pieces of glass, large pins, forks, and even open penknives have at one time or another found their way into the bowels. Though many of these bodies are of a formidable and rather dangerous character, it is nevertheless a fact, singu- lar as it may be, that in a great many instances, perhaps in the greater number, they have passed through the bowels without inflicting any injury. Though not properly pertaining to the subject under consideration, the following cases are recopied here for the great interest that attaches to them, and the important lessons they inculcate.
Case 1. Swallowing of open penknife. C. B. Hutchings, M.D. (Pacific Medical and Surgical Journal, 1886, XXIV. 35).
On the afternoon of Thursday, 19th, a young man twenty years of age, while fooling with some boys and girls, swal- lowed an open penknife, handle first. On telephoning the neighboring doctor, he was ordered to drink nothing but milk, and to take a dose of castor oil. Fortunately, this advice was not followed, and he came immediately to the city, where he arrived at 7.30 p.m. The castor oil was not given, but instead he was instructed to eat a hearty meal of mush and buckwheat cakes, and on going to bed directed to lie on his right side to facilitate the passage of the knife into the duodenum. The next day he was directed to spend most of the day on his riglit side with the hips elevated, and to eat freely of any food he desired, but particularly of buckwheat cakes. He claimed that he felt the passage of the knife through the ileo-csecal valve,
48
CONSTIPATION IN ADULTS
from the very considerable pain it caused. The bowels moved on Friday. On Saturday and Sunday the same food was pre- scribed, but on neither day did the bowels move. He claimed, however, that he felt the knife in the transverse colon, and on Monday in the sigmoid flexure, and late Monday he felt it sticking him in the neighborhood of the anus. The bowels did not move on Monday, but on Tuesday morning about 11 o'clock there was an immense movement, which brought away the knife, point first. ^
Case 2. Swallowing a plate with four teeth. M. L. Bates, M.D. (Transactions of the Medical Society of the State of New York, Vol. for 1886).
C. E. W., aged thirty-eight, came to my house about 1 o'clock in the morning of October 9, 1885, and after arousing me fi'om my slumbers, stated that about an hour before he was awakened from his sleep by a strangling sensation, accompanied by cough and choking. When sufficiently aroused from his sleep to know what was going on about him, he found that he had SAvallowed his teeth — artificial plate with four teeth attached; he expe- rienced also pain and a sense of oppression in the chest in the median line, directly over the sternum, and felt that the foreign body had lodged at some point in the oesophagus. As he was obliged to travel about a mile to reach my office, when he arrived there the pain and oppression had ceased, and he then experienced an uneasy sensation in the stomach. On examina- tion I found that the foreign body had probably passed into the stomach and that we must deal with the case from that standpoint. After obtaining a description of the plate, as to its size, etc., I informed the patient that it might possibly pass through the alimentary canal, but that if, in the course of six days, it should not pass, then the operation of gastrotomy sliould not be delayed. From the description of the foreign body given by the patient himself, I thought it impossible for
1 A diet of potato mush, i.e. mashed potatoes, has been highly recom- iiieiided for the purpose of enveloping, and thus rendering innocuous, sharp or pointed articles that may have been swallowed.
ACUTE CONSTIPATION
49
it to pass the pyloric orifice of the stomach. After giving him some directions he went away. On the morning of the sixth day he came to my office and informed me that the plate with all the teeth intact and encased in a pultaceous mass of fcTJcal matter passed his rectum that morning. He said that during the six days, no pain or even discomfort in any portion of his bowels was experienced.
2. Foreign bodies are introduced into the rectum for diverse and many reasons, and are likewise very varied in their charac- ter : spools, pieces of wool, tumblers, bottles, candles, pieces of iron bar, etc.
Case 3. Glass syringe broken in the rectum. N. M. Baskett, M.D. (St. Louis Courier of Medicine, 1891, IV. 76).
Mrs. B, a widow, aged somewhere between fifty and sixty, is lying at the point of death with phthisis pulmonalis and will probably not live more than a few weeks. I was called upon by one of her relatives last week, who wished to consult me concerning the constipated condition of Mrs. B's bowels. She had had no passage for six or seven days. ... I wrote for glycerine to be administered in two-drachm doses with a small syringe by injection. She stated that she had a small glass syringe, and I told her she could use that. She administered the glycerine successfully. . . . The bowels began to act frequently and exhaustingly, and during the night it became necessary to use means to check them, and the lady concluded to try the injection of ten drops of laudanum by the rectum. In introducing the syringe the cylinder of the instrument was broken in an oblique manner, and two-thirds of it drawn into the rectum. The piston and the other portion of the syringe remained in the operator's hands.
I was hurriedly sent for and the accident explained. I felt dubious concerning the matter, and I knew the danger of further fractures ensuing in any attempt to remove it. How- ever, it was no time for speculation. I greased my index finger, introduced it, and was so fortunate as to find the oblique fractured portion lying in such a position that I could
50
CONSTIPATION IN ADULTS
slip the end of my index finger into the tube without cutting the finger. I then forced my thumb up until I could seize it between my thumb and index finger, and luckily removed it without fractures. This was indeed fortunate as the glass was scarcely thicker than a good quality of writing paper.
Case 4. A piece of wood driven into the rectum. W. C. Jones, M.D. (Occidental Medical Times, 1891, V. 375).
On June 5, 1891, a Chinaman, sixty years of age, while mining in a ravine about two and a half miles from town, was approached by three men who demanded his money. They searched him and took all he had, — about three dollars in gold- dust, — but, thinking that by torture they could obtain more money, they sawed off six inches from the end of a hoe handle and forced it up the victim's rectum, wholly beyond the sphincter ani, and left him in this condition. This occurred at noon Friday. The following day, 10 a.m., he had walked to town and presented himself at my office. After some trouble, with a long pair of forceps, I grasped the foreign body, and as the not very carefully sawn end of the handle was downward, it required much force, and I presume pain, to deliver it through a strongly resisting sphincter. . . . The piece of wood was in the rectum twenty-two hours.
Bodies so introduced, if they be of sufficient size to be retained in the rectum, will set up, by the pressure and irri- tation exercised upon the mucous membrane, an acute proctitis, an ulceration of the mucous membrane, which may go on to perforation, and the formation of fistulous openings, or, if the condition present be recognized in time and the ulceration healed, may result in stricture of the rectum.
Again, bodies so introduced are, if they be not so large as to exert an inhibiting pressure upon the tissues of the rectum, transported upward by an antiperistalsis into various portions of the large bowel. Foreign bodies so introduced have been found in the sigmoid flexure, in the descending and in the transverse colon.i in their upward passage they are arrested
1 Most convincing demonstration of an anti-peristalsis, which has been questioned by some.
ACUTE CONSTIPATION
51
at one point or another, and an acute obstruction of the bowels, an acute constipation, is set up.^
(S) The foreign bodies formed in the intestinal tract are themselves the result of a greater or lesser degree of consti- pation, and will be considered under another head.
B. By i^citliolocjical changes in one or more of the tissues of the intestinal tract, impairing their capacity for normal joerformance of their j^^^l/^^ological function. This we find
In the acute inflammation of the various sections of the large or small bowel.
In the various forms of peritonitis. (It is the muscular coat of the intestine that is most frequently in- volved here ; it is infiltrated, tumefied ; and this, with the tying up of the intestinal tract by bands, the result of the inflammation, produces the con- stipation.)
In some cases of typhoid fever. (Here also the muscular layer has been found tumefied, and the mucous membrane very much infiltrated, so much so as to project into the lumen of the canal.)
C. By direct inhibition of peristaltic function through the nerve centres. This occurs
In acute cerebral meningitis.
In tubercular meningitis of acute form.
In apoplexy.
I71 acute mania.
1 For further information upon this topic the reader is referred to Poulet, Corps Strangers en Chirurgie (an English translation extant), Paris, 1879. Gerard, Camille, Des Corps Strangers du Rectum, leurs migration dans I'intestin, etc., Paris, 1878.
52
CONSTIPATION IN ADULTS
In various acute diseases of the spinal cord and its en- velopes. In acute infectious diseases. In hysteria.
Case 5. Adler reports a very interesting case : A young man, cet. seventeen, of German parentage, but educated in France ; neurotic tendency manifested since earliest child- hood ; neurotic taint in family. Claims to have suffered rather frequently in the last few years from attacks of colic, with constipation, distension of the abdomen, and great pain. These attacks were accounted for sometimes by dietary indis- cretion, at other times, no cause for their coming on could be discovered. Laxatives and belladonna were said to have relieved him in the course of a few days, provoking free dis- charge of gas and f^cal matter. The young man is organically sound, appears well nourished, has an excellent appetite, his digestion is good and his bowels are regular. All at once, without any known reason or cause therefor, he is seized with pain in his belly, with rumbling and gurgling therein, and dis- tention. The belly grows rapidly in size, and in twenty-four hours has reached enormous dimensions. The diaphragm is pushed high up, the abdominal walls are tense to bursting, and the whole abdomen is very sensitive to pressure. No fever, pulse quiet, and but little more frequent ; tongue clean ; vomit- ing rare, — only after certain articles of diet. Urine normal, but rich in phosphates. Urination rather difficult, probably in consequence of the great meteorism, so that the catheter must be resorted to several times. It is impossible to obtain an evacuation or to effect the discharge of even a little flatus. Laxatives administered are vomited ; those retained prove m- effective. As for rectal injections, but small quantities are tolerated, and these are again at once discharged, having had no effect. Digital examination of the rectum discloses a strongly dilated ampulla and so far drawn up that the internal sphincter cannot be reached with the finger ; otherwise nothing abnormal. This condition continues for five or six days. 1 he
ACUTE CONSTIPATION
53
diverse remedies, both internal and external, prove inelfective. Atropine is not tolerated at all ; not even in minimal doses. Suddenly, after a few doses of the extract of Calabar bean and of nux vomica, fsecal evacuations with abundant discharge of flatus follow, and the patient is well. He remained well for a few months, and then had another and much severer attack. The belly became distended, assumed in a few hours incredible dimensions. Respiration was very much embarrassed ; patient could lie only on his side, and then suffered greatly. This time the Calabar bean and nux vomica were without effect, and he remained in the state described for nearly a week. Then, upon a rectal injection of warm water to which a few drops of valerian had been added, fsecal and gaseous discharges followed, and the patient was well. The attacks recurred in the course of the following month. The patient returned to France, and was thus lost sight of.^
Adler believes that the acute constipation was the result of a spasmodic stricture suddenly developed ; there is, however, nothing in the history or in the examination to show that such was the case.
If it is true that hysteria may be the cause of a spasmodic stricture, and that it may so act upon muscle is well demon- strated, it is likewise undoubted that it may act in a manner directly the opposite, i.e. inhibiting the normal nerve tonus and producing a paretic condition. 2 The acute cases, as the one described, are undoubtedly due to the latter mode of action, for reasons readily apparent.
D. By absence of, or impairment of the quality of the bile.
In the various acute diseases of the liver. In cholelithiasis during the passage of the gall stone through the common duct.
^ New Yorker medicinische Monatschrift, 1892. See Rosenthal, Diseas. of the Nerv. Syst. Charcot, Le(^. sur les Mahad. du Syst. Nerv. Gowers, Dis. of the Brain and Spin. Cord.
54 CONSTIPATION IN ADULTS
E. By inUUtion of the aid of the diaphragm and ab- dominal muscles.
In acute diseases of the lungs and pleura.
In rheumatic diseases of the abdominal muscles.
In hyperaesthesia of the abdominal parietes.
In paralysis of the diaphragm and abdominal muscles.
In acute diseases of the female genital tract.
F. Refiexly.
In the inflammations of retained testicle.
In some of the acute diseases of the female genital tract.
In acute diseases of the bladder and prostate.
G. By a combination of these various loays.
In acute inflammations of the stomach. In attacks of gout.
In all the various forms of constipation here considered, with the exception of groups "A" and " C," there are other circumstances, additional to the principal ones already named, that tend to produce the constipation. These are: The abstemious diet to which the patient confines himself already in the prodromic stage by reason of the loss of appetite; the sudden change in the char- acter of the food, which in the invalid state consists altogether of bland, non-irritating articles ; the small quantity of food taken ; the recumbent position ; the want of the usual exercise ; frequently, also, the medication.
The pathology of the various morbid states referred to in this category as well as the treatment thereof are found in extenso in the numerous text-books, and the more pretentious works both on medicine and surgery, and in special treatises.
ACUTE CONSTIPATION
55
This category of constipation, as has already been indicated, does not concern us. It is not the constipation that requires our attention here, but the pathological process of which it is but one of the symptoms.
However, there are a few points relating to group "A" to which I would briefly call attention:
1. The Bauhinian valve can be passed by fluids injected with some force into the rectum.^
2. Injections of large quantities of water with the powerful pump described in my paper on Intestinal Obstruction^ are of the greatest value both as to the restoration of the normal status where such is possible, as in the various forms of intussusception and of volvu- lus, and as to the clear and distinct indication for opera- tive interference where such restoration to the normal does not at once result.*^ The long delay which greatly diminishes the chances of the operative procedure, and is therefore fatal to the patient, is done away with.
3. The value of the alternate use at brief intervals of hot and cold water, or hot and cooler water, according to the indications. I believe I can claim for myself priority in the use of hot water for rectal injections in the treatment of the conditions referred to, and in the use of hot water of a temperature of 106° F., for rectal injections, as, previous to the publication of my article, no such injections were described, at least not to my knowledge.
^ See my article "Intestinal Obstruction," American Journal of the Medi- cal Sciences, January, 1886. Senn, Experimental Surgery, Chicago, 1889, p. 479. 2 Ibid.
8 See the casuistry in the article " Intestinal Obstruction," American Journal of the Medical Sciences, loc. cit.
CHAPTER VII
CHRONIC CONSTIPATION
Considering the varied nature of the etiological factors that give rise to it, chronic constipation is best studied subdivided, according to the mode of its production, into the following four groups :
A. Chronic constipation produced by well-defined mor- bid processes.
B. Chronic constipation by obstruction from foreign bodies.
C. Chronic constipation produced by congenital mal- formation of a section of the large bowel, or by defective development of the intestinal tract, or by dislocation of any part thereof.
D. Chronic constipation from impairment of physio- logical functionmg alone.
Section I. Chronic Constipation from Disease
The morbid processes which cause chronic constipation do so in various ways :
1 . By obstructing the lumen of the tube :
Cicatricial narrowing of any portion of the intestinal tract (as the result of the healing of an ulcer, or after dysentery).
56
CHRONIC CONSTIPATION
57
Constriction of a section of the intestinal tract by bands
(after peritoneal inflammation). Constriction of the ctecum and of the jejunum (after
typhlitis or perityphlitis). Cancerous disease of the large bowel (the rectum is the
part most frequently affected). Tumors in the abdominal cavity pressing upon the bowel
and occluding it.^ Massive exudations of blood (hgematocele), or of serum,
into the cellular tissue of the pelvis. Obstruction of the rectum by a retroverted uterus. Tumors within the rectum. Folds of mucous membrane.
Kesley,2 in a clinical lecture, refers to a patient long afflicted with constipation, in whom, on downward pressure at stool, large and abundant folds of mucous membrane came down which completely cut off the orificium ani from the rest of the rectum. As he says, it is " a prolapse which does not protrude."
2. By impairment of the secretions poured into the in- testines :
In chronic diseases of the liver, when the secretion of the bile is deficient, or perhaps almost altogether wanting ; or when the bile secreted is not of normal character.
In diseases of the pancreas. Constipation is rather fre- quent in the diseases of this organ, and adds greatly to the severity of the suffering.^
1 Rosenblatt {Centralhlatt f. Chirurgie, 1882, No. 29, p. 64) reports a case of complete intestinal occlusion produced by a cyst of the pancreas.
2 New York Medical Journal, May 16, 1896.
' Hinrichs, " Beitrag zur Lehre v. d. Erkrankungen des Pancreas." Inaug. Dissertation, Berlin, May, 1889.
58
CONSTIPATION IN ADULTS
3. By inhibition of peristalsis through the nerve cen- tres :
In chronic diseases of the brain.
In chronic affections of the spinal cord and its envelopes. In chronic forms of insanity.
In saturnine intoxication (lead paralysis; saturnine en- cephalopathy).
In tabes dorsalis (locomotor ataxia) most obstinate constipation is frequently observed. Henrot reports an instance in which a constipation so obstinate supervened that the original nervous affection was lost sight of, and an intestinal obstruction presumed. An autopsy shoAved the tube free from all lesion or obstruction, and revealed marked atrophy of the cord, both of the anterior and posterior spinal roots.'
In the paralysis after diphtheria.
4. By chronic venous congestion of the intestinal circu- lation :
In organic disease of the heart.
In some chronic pulmonary affections, as asthma, em- physema, etc.
5. By voluntary abstention from stool on account of the pain it causes by reason of a diseased condition of the rectum :
In hsemorrhoids.
In ulcers of the rectum.
In fissure of the anus.
1 Henrot, Des Pseudo-Etrangleinents, Paris, 1865.
CHRONIC CONSTIPATION
59
In chronic inflammation of the rectum (chronic proctitis). In abnormal irritability of the rectum, — ''irritable rectum, hysterical rectum ^
6. By changes in the mucous membrane which impair its irritability, and if they involve a more or less exten- sive portion of it, render it incapable of performing its physiological function in the process of digestion :
In saturnine intoxication.^
In chronic catarrh of the small intestines.^
In membranous enteritis.
In the two latter diseases there are several other fac- tors that can be regarded as assisting in the development of the constipation and its persistence, viz., change of diet (as most patients so afflicted confine themselves to bland, unirritating food, of a concentrated nature, having but little residue), restriction in quantity, etc.
In atrophy of a section or sections of the intestinal mucous membrane (after catarrhs).'^
7. By atony of the intestinal muscles produced by mor- bid conditions of the stomach or of the boivels :
In atony of the stomach.
In some of the cases coming under my observation, I was inclined to believe that the atony of the stomach was secondary to the atony of the intestines.
In dilatation of the stomach.
^ Where the lead has as yet acted locally oiily.
2 It is almost an aphorism that catarrhal disease of the small intestines is attended by constipation, whilst diarrhoea is a prominent feature of catarrh of the large bowel.
' Nothnagel, Beitrage z. Physiol, u. Pathol, d. Darmes.
60
CONSTIPATION IN ADULTS
The solids and fluids ingested are retained for an undue length of time in the stomach, and pass out but very slowly and in very small quantities. In fact, stagnation is its characteristic feature. No doubt that the intestinal muscles, also, are in an atonic condition. It is not un- likely that some of the intestinal structures, the mucous membrane most probably, are in a morbid state.
Gastric and intestinal dyspepsia (so-called) are said to cause constipation. I have not considered them among the etio- logical factors for the reason that I hold, without going here into the question what is dyspepsia^ that constipation is not at all one of their symptoms, and when it is present, it is not the result of the morbid state of the stomach or bowels. It is due to the fact that these patients reduce their diet greatly both in quantity and quality, confining themselves, almost exclusively, to bland, concentrated material. Not infrequently the dyspep- sia is the result of the constipation.
As a sequence of prolonged catarrh of the large bowel.
Section II. Chronic Constipation from Foreign
Bodies
The foreign bodies that give rise to chronic constipa- tion are such as are of gradual growth, whether the materials of which they are formed are excretions or abnormal formations of the body, or are introduced from without.
Case 6. Intestinal obstruction hj a mass of hair. Dr. Tefft.
A young girl, cet. seventeen, of sickly aspect, has long had the habit of swallowing all sorts of things. About her fifteenth year she menstruated at two periods, but never after that. She sickened ; complained of cardialgia and of head-
CHRONIC CONSrrPATlON
61
ache ; vomiting and diarrhoea ^ supervened ; she emaciated markedly and lost greatly in strength. The vomiting was so incessant that all nutrition was inhibited. Gradually the belly became painful to the touch , the presence of a tumor, not depressible, indolent, hard, cylindrical, without fluctua- tion and occupying all the region between the anterior border of the ninth rib and the anterior superior spinous process of the ileum, was noted. On percussion, the region occu- pied by the tumor gave a dull, flat sound, whilst the other portions of the abdomen resounded rather sonorously. The vomiting soon became faecal, the constipation absolute, and death soon closed the scene. At the autopsy it was found that the tumor was formed by the csecum and ascending colon, which were filled with a foreign voluminous mass. This mass, which tapered off at its upper extremity, where it penetrated into the ileum through the ileo-csecal orifice, was fifteen centi- meters long and composed at its base of a mass of hair mixed with excrementitious material ; the upper portion was a mass of cotton, and that part of it which penetrated into the ileum consisted of threads of flax and pieces of packthread. ^
Case 7. Voluminous intestinal concretions. Pupier. Z.
M. Pupier presented to the Medical Society of Lyons a cal- culus still greater than the one presented by M. Andry (which weighed forty grammes), weighing fifty-eight grammes, com- posed of almost pure cholesterine, and discharged only after a labor very much like that of an accouchement. The patient, a colleague, had never suffered from frank hepatic colic, though he frequently had pain on going to stool (before the evacua- tion), or felt some embarrassment about the level of the caecum; the stools were colorless. By means of purgatives the calculus was dislodged, but not until after an anal drama, to use the picturesque phrase of tlie patient, which lasted over forty-eight hours. According to the victim of this accident, it is probable
^ This form of diarrhcea will be referred to again further on. 2 Schmidt's Jahrbilcher, 135, p. 74. Also Poulet, Corps Strangers en Chirurgie.
62 CONSTIPATION IN ADULTS
that the powder of cholesterine accumulated for a long time in the ca3cum and there formed a mass.i
It has already been said, and it is, I think, rather clearly demonstrated by the above histories, that such accumulations, especially as the one in case seven, are really themselves the result of a previously existing con- stipation or insufficient activity of the bowels ; for with a normal activity of the intestinal tract and a normal cleansing thereof, no such accumulation could occur; certainly not very easily. Undoubtedly, when the mass has attained a sufficient size, it tends to aggravate the already existing constipation.
Section III. A. Malformations of the Intestines
The malformations of the intestines are most varied in their nature, and may involve any and all parts thereof. Greig ^ describes a case in which the major part of the small intestines was entirely wanting. Atkins'^ reports the history of an infant in whom the large bowel was found in a rudimentary state, and seemed, at first glance, impervious. On removal, however, of the whole alimentary tract, it was discovered that by the exercise of considerable pressure, a little meconium could be squeezed out. Other and more frequently occurring ab- normalities will be referred to more in detail in the section treating of the constipation of infants. All these forms produce a constipation that belongs in the cate- gory of the acute, and are either altogether incompatible
1 Lyon Medical, 1887, LIV. 546.
2 Canadian Practitioner, February 16, 1893. Sajoii's Afinual, 1893, Vol. V. 8 Lancet, London, 1885, VoL II.
CHRONIC CONSTIPATION
63
with life, or require prompt surgical interference for their relief.
The malformations that are compatible with a more or less prolonged existence and that give rise to a state of chronic constipation, to a retardation of faecal dis- charges, are, so far as hitherto reported :
1. Abnormally developed colon.
2. Undue length or size of sigmoid flexure.
3. Diverticula of the large bowel.
The true diverticulum of the small intestine (diverticulum ilei^ Meckel's diverticulum'), if it prove an obstacle to defecation, does so by constricting or strangulating a segment of the intes- tine, and the constipation thus resulting is consequently of the acute variety. 1
The false diverticula of the small intestines are, in so far as their influence on the movements of the bowels is concerned, harmless. 2
4. Diaphragms in the large bowel.
From what has already been said in the chapter on "Intestinal Peristalsis," it can be at once understood how the conditions just named should give rise to a state of chronic constipation. For better illustration, a few of the cases coming under the various heads have been excerpted.
1. Abnormally Developed Colon.
Case 8. Chicago Medical Journal, 1867. Dr. William Lewitt.
A young man, cet. twenty-one, was constipated ; had not had an evacuation for three weeks. The patient was found suffering
^ Osier, Annals of Anat. a. Surg., Brooklyn, 1881. Treves, Intestinal Obstruction.
^ Treves, loc. cit.
64
CONSTIPATION IN ADULTS
intense pain in the abdomen, with frequent desire to expel flatus from the rectum, which he could accomplish only by standing upon his head and hands in a perpendicular position. The abdo- men was enormously distended, and so tense that it was impossi- ble to feel the outlines of any abdominal organ. He had had a similar attack when he was about twelve years of age, and has ever since then been suffering from torpor of the bowels, hav- ing an evacuation only once in eight or ten days. Upon exami- nation per rectum, there was found what appeared to be an enormous tumor filling up the entire pelvic cavity. The rectum appeared to be normal. . . . About a week after the first visit, the patient was seized one day with excruciating pain in the abdomen, and, after a few hours, expired.
Post mortem examination^ six hours after death. The peri- toneal cavity was enormously distended with gas, and a large quantity of fsecal matter of battery consistence was extra vasated into it, showing that perforation had taken place, and was the immediate cause of death. Perforation had taken place at several points in the colon. The ascending and descending colon (for there was no transverse) appeared like two immense cylinders, lying side by side, and extending from the epigas- trium to the pelvis, and filled with soft fsecal matter, and each was about five and one-half inches in diameter. The caput coli was not much enlarged ; the transverse colon was entirely obliterated, and the two cylinders of the ascending and descend- ing colon were folded upon themselves, filling up the entire abdominal cavity. The sigmoid flexure was about the same diameter, and what was supposed to be the tumor filling up the pelvic cavity was the sigmoid flexure enormously distended with fcBcal matter, and folded down upon itself, giving it the firm and rounded shape of a tumor that was supposed to exist, and pressed so firmly down upon the upper portion of the rectum as to prevent all passage of ftecal matter into it. The colon was very much thickened, and completely filled with fiecal matter of a battery consistence, containing over a large wooden pailful, besides what had extravasated through the perforation into the peritoneal cavity.
CHRONIC CONSTIPATION
65
The reason for his adopting that peculiar and unnatural posi- tion to enable him to expel the flatus from his bowels was, that by that position the weight of the distended sigmoid flexure was taken off the upper portion of the rectum, and allowed a small quantity of flatus to escape, which afforded him some relief.
I have no doubt that the change of position and the enlarge- ment of the colon were congenital. The youth of the patient, the early age at which his trouble began, seem to clearly demon- strate this, and, although we have no history of constipation to his twelfth year, it is more from ignorance or inadvertence.
Case 9. Enormous congenital development of the colon. Dr. Formad (University Medical Magazine, June, 1892).
I. W., cet. twenty-nine years, white, single; was found dead in the water-closet of the society to which he belonged. . . . His mother tells that up to the age of one and one-half years, the subject under consideration was a normal infant, with the exception of a rather large abdomen, frequent irregularity of the bowels, and attacks of constipation ; but no other de- formity of the body had been noticed up to that time. Sub- sequently, and especially noticeable at the age of two years, the abdomen began to swell and the disturbance in defecation to be more marked, so that constipation would last from two to four days as a rule. His appearance was said to have been that of a marasmic child, lean and emaciated, and until five years of age he was unable to rise without assistance. Subsequently the bodily development was progressive, although he was rather spare. At the age of twelve years he was able to go to school, and, although the history of his intellectual success as a school- boy is uncertain, he appeared to have had the normal intelligence of lads of his age. At the age of sixteen, he earned his living at a foundry for eighteen months at continuous work. Subse- quently he worked for several years as a laborer at an oil refinery, and while his work was uninterrupted during this period, his parents say that he was subject to habitual constipa- tion, said to last as long as a whole month at a time, although
66
CONSTIPATION IN ADULTS
no correct clinical data covering thi^ period of his life could be obtained. Yet it was obvious that his abdomen continued to grow in size. At this period of his life, while not feeling dis- tressed by any painful ailment, he is said to have visited the dispensaries of various hospitals of this city. At twenty years of age his abdomen had reached very large dimensions, and the figure of his body became so peculiar that the manager of the Ninth and Arch Streets Museum saw fit to put him on exhibi- tion as a freak, and for eight or ten years he was known as the " Windbag or balloon man." . . . The whole history of his life and habits does not present anything peculiar, except that he had an enormous appetite, and was generally a good feeder. He was known to relish a few heavy meals a day. He was occasionally of intemperate habits.
Autopsy twenty-four hours after death.
Abdomen. — No excess of the peritoneal fluid, although the surfaces of the peritoneum had an unusual degree of moisture. The color of the surfaces was normal, no evidence of any hyperemia or inflammatory conditions in any part. A most striking appearance was presented by the colon. It was dis- tended by fjecal contents and gas, and, although occupying a normal direction in the abdomen, it was of huge dimensions, and occupied a large portion of the thoracic region of the body. By a rough estimate it had the appearance of being at least ten times wider than normal, the exact measurements being as follows: total length of colon, 2.52 metres (about 8 feet 4 inches). The rest of the figures relate to the circumference of the bowels. Cificum, 26 cm. (10 inches); colon, ascending part, 37 cm. (15 inches); colon, transverse part, gradually increasing from 38 cm. to 76 cm. (15 inches to 30 inches); colon, descending part, 60 to 62 cm. (24 to 25 inches); sig- moid flexure, 62 to 69 cm. (25 to 27 inches).
The mesocolon was abnormally large and thick, which, how- ever, was perfectly consistent with the enormous hypertrophy of the colon.
Human colon, congenital giant growth and coprostasis. Tlie more distended end is the sigmoid flexure. The narrow part taking exit from it represents the greater part of the rectum, which was normal. Tlie narrow distal end of the preparation represents the head of the colon with the string attached to a fragment of the small intestine. The arched part of the specimen represents the transverse portion of the colon. — The figure within represents a normal human colon photographed simulta- neously for comparison of dimensions. Dried preparations.
G7
68
CONSTIPATION IN ADULTS
The whole of the colon thus presented a gradual increase in size or width from the csecum to the sigmoid flexure, the great- est increase in width being in the transverse portion.
***********
The contents of the colon was represented by two pailfuls of fceces, which weighed forty pounds. The physical character of the fffices appeared to be normal, appearing as a semi-fluid, dark- brown mass, with, perhaps, a greenish tinge ; microscopically and chemically nothing abnormal was discovered.
The rectum was perfectly normal in dimensions ; its muscu- lar coats were quite thick, and it presented a striking transition from the extreme dilatation of the sigmoid flexure and rest of the colon above, to that of contraction, althougli no abnormal ana- tomical appearance of contraction that could have led to any obstruction could be discovered either in the rectum or anus.
This remarkable excess in size was, however, limited to the large intestine, the small intestines as well as the rest of the alimentary canal being of normal dimensions.
2. Undue Size of Sigmoid Flexure.
Case 10. Miormous dilatation of the sigmoid flexure. Dr. Harrington (Chicago Medical Journal and Examiner). ^
I was called January 31 at 10 a.m. to see J. B. Farmer, aged fifty-one years, suffering from intense pain. He had been subject to bilious colic for nearly ten years, during which he vomited frequently and severely and suffered from severe pain in the bowels. He had been troubled with constipation, espe- cially preceding these attacks. He had also not felt well for nearly a week, and the day previous began having severe par- oxysmal pains in the bowels, accompanied by nausea and vom- iting, which continued during the night, and were still present. The skin was about normal ; tongue dry, white fur in the centre; pulse 70, soft; temperature normal; appetite lost;
1 Vol. XXXVL, 1878, p. 400.
CHRONIC CONSTIPATION
69
bowels constipated; abdomen slightly tympanitic, and some- Avliat tender ; no tumor could be felt ; the material ejected by vomiting consisted of bile, mucus, and fluid taken into the stomach.
The patient frequently tried to eject gas from the stomach by belching. The swelling of the abdomen kept increasing until midnight, becoming finally enormous, and causing great distress. ... I passed a No. 10 catheter into the stomach, when quite a quantity of gas escaped. The abdomen was so tense that it seemed as if the gut must rupture. A distinct ridge revealed (as I thought) the outline of the distended colon. ... I kept him quiet with hypodermic injections until Dr. S. M. Hamilton, of Monmouth, who had been called in consultation, agreed with me as to the necessity of tapping, and very skilfully operated, perforating, as we supposed, the ascend- ing colon, and giving vent to a very large quantity of offensive gas. This gave great relief. ... At 11 o'clock I tapped the bowels again about one-half an inch above the first puncture, permitting the escape of a still larger quantity of gas. . . . He rested quietly until 3.30 o'clock a.m., when he began to sink, and died at half-past four.
Autopsy ten hours after death. Rigor mortis marked. On opening the abdominal cavity, I cut down upon what proved to be an immense sac-like dilatation of the sigmoid flexure which entirely covered the anterior surface of the bowels, and which we had punctured on the right side, instead of the ascending colon ; it extended as high as the cruciform cartilage, and was perfectly black from congestion. Further examination revealed extensive enteritis and general peritonitis. The sac was empty, its walls thick and muscular, and it would hold at least a gallon. No faecal accumulation in any part of the bowels. No apparent contraction below the sac. No morbid deposit in the walls of the rectum. The liver and spleen were congested and some- what softened ; other organs healthy.
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CONSTIPATION IN ADULTS
Case 11. Abnormal congenital development of the sic/moid flexure. Intestmal oeclusio7i. Dr. Eisenhart (Centralblatt f Innere Medicin, No. 49, 1894).
Patient female, est. thirty-five years ; has always suffered from constipation and therefore resorted to various purgatives, so that she had an evacuation once in three or four days. In the year before, in consequence of a puerperium, she suffered a strong psychic disturbance and was placed in an institution for treatment. At this time a condition developed very much like the present : obstinate constipation, great distension and tenderness of the abdomen, nausea without vomiting, and marked disturbance of the general health. After many things had been tried, a drastic purge was given per os on the tenth day and an evacuation resulted, whereupon the patient rapidly recovered. Torpidity of the intestines as before.
Two days ago she was seized with pain in her belly, which day by day increased in severity and duration. At the same time a rapidly growing distension of the belly manifested itself and in consequence thereof there was marked disturbance of the general health, loss of appetite, and loss of sleep. No evacua- tion of the bowels in two days.
I saw the patient for the first time on October 5, 1893. She lay in bed moaning and complaining ; face anxious and pain- ful in expression, but fresh in appearance. Axillary tempera- ture 37° C. Pulse 78. Abdomen greatly distended, like that of a gravid woman in the last weeks ; greatest circumference, 103 cm. ; distance from symphysis to navel, 16 cm. ; from symphysis to xiphoid cartilage, 41 cm. Beneath the thin but otherwise unchanged abdominal walls, the greatly distended intestines, in very slow but uninterrupted peristalsis, are plainly visible ; from up on the right side diagonally down- wards to the left there stretches a segment of bowel which from its size (thickness of a man's arm) and its configuration (constrictions) appeared to be the transverse colon. The abdomen is painful to the touch, for the reason that peristaltic movements are thereby provoked. Vaginal examination, in so far as a result can be obtained without bimanual examination,
CHRONIC CONSTIPATION
71
which was impossible, disclosed a normal condition ; retroflexion of the uterus, which, as is well known, may cause occlusion of the bowel even in the non-gravid female, can be excluded. The rectum, so far as the finger can reach, free. No hernias.
The various means and measures resorted to for the relief of the occlusion proving fruitless, Professor Dr. Bauer was called in consultation; surgical interference advised, and the patient transferred to the surgical clinic. October 13, a coeliotomy was made. The extremely distended segment of bowel covered the whole field of operation, and rendered a recognition of localities rather difficult. An incision was there- fore made into it, and although gas and a considerable amount of semi-solid fjBcal matter were evacuated, but little diminution in size resulted. (The incision was immediately closed with sutures.) Nevertheless, it was now possible to recognize the obstructions ; in the region of the sigmoid flexure the bowel was bent upon itself at a sharp angle, and several loops of the small intestines had passed through a slit in the mesentery and become thereby constricted. The obstructions were removed and the wound closed. The expected result did not follow. A few hours after the operation the previous condition of things again prevailed, and before the abdomen could be opened the second time the woman died, on the afternoon of the day of operation.
Post-mortem Examination. — The so enormously developed segment of bowel was not the transverse colon, as had been supposed, but the sigmoid flexure. It was about 60 cm. long, and lay in the form of an arc from the left side over and up to the right, and down on to the left, passing into the normal rectum. The lower segment of the flexure near its junction with the rectum, having become overfilled, was dragged down- ward, bent at a sharp angle, the rectum closed off, and the occlusion thus produced. The subsequent peristalsis drove the contenta more and more into the diverticular-like space, and by the pressure thus made the upper portion of the rectum was
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CONSTIPATION IN ADULTS
being constantly drawn downward, and was thus more and more shut off.
Width of flexure laid open, 33 cm. (normal width, according to Cruveilhier, 14 cm.).
3. Diverticula.
Case 12. Congenital diverticulum of the sigmoid flexure. Drs. Fiitterer u. Middendorpf (Virchow's Archiv, Bd. 106).
Chr. H., fourteen years old; admitted to Julius Hospital, February 3, 1886. The father of the patient is alive and in good health, but the left side of his face, especially the left half of the lower jaw, is less developed than the right side. . . . Already at his birth, which was a perfectly normal one, the jDatient is said to have had an unusually large belly, larger than other children. Its circumference increased in the fol- lowing years slowly but steadily; he, however, suffered but little inconvenience therefrom. He went to school and was a good scholar. About a year ago there was such a marked increase in the circumference of the belly, that he could not attend school regularly, and if he ran a little he lost his breath. No palpitation, patient claims. . . . He had about three stools daily.
Status ProBsens. — The great distension of the abdomen has produced a distension of the lower portion of the thorax. The skin of the abdomen is pale, drawn very tense, not oedema- tous ; on the anterior surface, corresponding, about, to the course of the vena epigastrica inferior, the veins are dilated and show tlirough with a bluish tint ; a similar network of dilated veins is seen on the outer side of the abdomen, about the region of the axillary lines. The abdomen is symmetrically distended, barrel-shaped; no tuberosities or protuberances noticeable anywhere. Eight centimetres above the navel and more particularly upon the left side, there are indications of a slight, horizontal, transversely running constriction. The navel is pushed out on a level with the rest of the abdominal surface. No especial changes to be seen on deep respiration or on change of position.
CHRONIC CONSTIPATION
73
The circumference of the thorax, on a level with the niam- milljB, 75-|- cm.; circumference of the abdomen on a line Avith the navel, 91 cm. ; greatest circumference at a point 8 to 10 cm. above that of the preceding measurement, 100 cm.; distance from navel to xiphoid cartilage, 28 cm. ; from the navel to the symph3^sis, 21 cm.; from the navel to the anterior superior spines of the ileum, right and left, 26 cm.
***********
Percussion of the abdomen with the patient in dorsal decu- bitus gives everywhere a tympanitic sound ; about 3 cm. above the symphysis and in the direction of the musculus quadratus lumborum, right and left, this becomes a dull tympanitic one ; absolute dullness nowhere. The patient sitting upright, absolute dullness or flatness cannot be made out anywhere ; the bounda- ries are very nearly the same in the sitting or lying position. . . . Auscultation of the abdomen, negative. The abdominal walls are very tense ; more solid masses that could lead to the assumption of a knotty tumor are nowhere to be palpated. On striking the abdomen on one side, the wave is distinctly per- ceived on the opposite side and in the middle about the navel ; the same result with the patient sitting upright or lying on either side. The consistency of the liver, soft, elastic. No swelling of the inguinal glands ; no oedema of the lower extremities.
The finger introduced into the rectum readily sweeps the promontory ; nothing abnormal about the pelvic organs ; strik- ing the anterior abdominal parietes, the point of the linger perceives the wave, though rather indistinctly, on the anterior rectal wall.
Urine scant, acid, opaque ; contains albumen, but no sugar. Sediment consisting of amorphous urate of soda and crystals of uric acid. February 4, one litre of warm Avater is injected . into the rectum ; the point of the stomach tube (English), which was readily introduced to the height of 20 cm., could be felt 8 to 10 cm. to the left of the navel, and on a level with it. Nothing special found on percussion after the injection. Ap- petite moderate ; fever none.
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CONSTIPATION IN ADULTS
In the following days two semi-solid, pap-like stools were obtained daily by means of mild cathartics and daily injections, the point of the rectal tube being easily pushed up to the left costal border, about 30 cm. from the anal orifice. The faeces had always the same grayish-brown, dark color ; odor not par- ticularly offensive. By reason of the abundant dejections, the circumference of the abdomen decreased, and by February 8 this diminution reached 5 cm. ; the belly became softer, but no difference on percussion could be noted; not even after the injection of two litres of water. Urine, daily quantity, 700 to 800 c. cm. Albumen disappeared after the third day of his sojourn in the hospital ; the sediment disappeared likewise.
On February 6, when the abdominal walls had become very much less tense, and the circumference of the belly had decreased 3 cm., there was very plainly felt, on rectal palpa- tion, above the promontory, a soft elastic swelling with smooth surface, and not delimitable upwards by palpation. Striking the belly, the concussion of a slight wave could now be clearly felt in the rectum. Temperature within normal limits.
February 8. An injection of one litre of lukewarm water was made this morning, and was followed by copious stools. Twenty drops of tincture opii are then given, and whilst the patient is narcotized, a trocar of moderate calibre is pushed into the left lumbar region, where a dull tympanitic sound had responded to percussion, and a grayish-dark, fluid, fsecal-like, odorless mass is evacuated, in which, upon microscopic exami- nation, undigested muscle fibres are found.
The rectal tube was now introduced to the height of 25 cm., and the point could be plainly seen and distinctly felt from the exterior. An incision 4 cm. long was made in the linea alba, through the attenuated abdominal parietes, about 5 cm. below the navel. After dividing the peritoneum, there appeared in the line of the incision numerous dark, bluish red, turgescent, easily compressible veins, 2 to 3 cm. in calibre, which ran m all directions upon the grayish white and very tense wall of a cyst. Intestines were not to be seen. No ascitic fluid. There benag great danger of haemorrhage from the enormously dilated veins,
CHRONIC CONSTIPATION
75
the operation was discontinued, the wound closed with three rows of sutures and an antiseptic dressing put on. . . . The patient never complained of pain ; it was only the meteorism that annoyed him, and the stomach tube had to be introduced about four times a day to relieve him ; frequently even this did not avail.
jifjie*********
During his stay in the hospital, the patient took but very little solid food. He lived almost exclusively upon eggs and Tokay wine. The amount of fseces was never in proportion to the amount of food taken, but always four to five times, frequently more, in excess.
Post-mortem Examination. — Emaciated male cadaver ; abdo- men very much distended. On laying open the abdominal cavity, a sac is cut into, whose tensely drawn anterior wall is in close apposition to the very much thinned abdominal walls, and large quantities of very fetid gas are set free. It is more than half filled with fluid fieces (eight litres), and occupies the whole abdominal cavity. The diaphragm is pushed far up and stands to the right, in the mammillary line, at the fourth rib ; to the left, at the lower border of the second rib.
The stomach lies in the left concavity of the diaphragm and its greater curvature runs in the parasternal line, about four fingers' breadth above the costal arch ; almost the whole bowel lies up here and behind it, and maintains this position even after the above-mentioned sac has been evacuated. Both kid- neys are in the normal position, and show no changes. The liver lies in the right concavity of the diaphragm, and is like- wise pushed up ; its lower border, in the mammillary line, four fingers' breadth above the costal arch.
In the stomach there are found, in small quantity, thin, bright-yellow, faecal masses; the mucous membrane is un- changed. The mucous membrane of the small intestines is discolored a slaty gray ; that of the large bowel, which con- tained hard fsecal masses, is similarly discolored.
The colon descendens, which is markedly contracted at its
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CONSTIPATION IN ADULTS
lower portion, opens into the enormously dilated sigmoid flex- ure. . . . The colon descendens is united to the upper and anterior portion of the sac by a mesentery which is 8 cm. at its longest point ; it has a calibre of 3.5 cm. at its point of flexure into the transverse colon, becomes smaller as it descends, until just at the opening into the sac, it is not more than 2 cm.
The longitudinal muscular fibres are here so closely pressed together that the individual taenisB cannot be delimited from one another, whilst toward the convexity of the dilatation, they radiate out as thick, hypertrophied bundles of muscular fibres. The mucous membrane of the colon descendens, besides the discoloration described, shows at irregular intervals (0.5 to 1.0 cm.) small, brown, roundish, spots and points from the size of a pin's head and smaller.
At the entrance into the sac the colon is so narrow that it is only with great effort that a finger can be pushed through it.
The mucous membrane of the dilated portion shows every- where a rosy color, and is abundantly covered with depressions and brownish spots, like those above mentioned, though they are somewhat paler here and not so well delimited. No ulcera- tion. The thickness of the mucous membrane, which averages about 1 ram., is subject to but slight variations. The muscu- lar coat, strongly hypertrophied, has a thickness anteriorly of 2 mm. ; posteriorly, of 5 mm.
Looking for the exit into the rectum, there was found at the lower and posterior section of the sac a semicircular slit, the concavity of which was directed upward and backward. A finger pushed through the slit, downward and forward, will be observed to glide along the lower wall of the sac, arch- ing it forward, for a distance of 8 cm. before it reaches the rectum, which had been cut open to the sac. The loAver ante- rior wall of the sac had here bent over on to the anterior wall of the rectum and the two became firmly united.
The mucous membrane of the rectum showed, with the exception of brown spots, like those already mentioned, noth- ing abnormal. The rectum was of normal width.
CHRONIC CONSTIPATION
77
The exit of the dilatation was 47 cm. below the entrance, whilst the circumference of the sac was 66 cm.
It took 16 litres of water to fill the sac, and when it was held out free by its anterior upper wall, no water ran off.
1, Descending colon ; 2, Dilated sigmoid flexure ; 3, Rectum.
The reporters, from the arguments adduced in the discussion of the case, conclude that the malformation was a congenital diverticulum of the sigmoid flexure.
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CONSTIPATION IN ADULTS
4. Diaphragms. — A fold of mucous membrane projects into the lumen of the bowel, and, according to its size, obstructs more or less the free passage thereof. It may stretch from wall to wall, and will then form a complete barrier to all communication between the part above and that below it; then, unless it be perforated, life is im- possible. It may be in the form of a shelf, and it is in this way that it most frequently occurs, leaving a smaller or larger passage of intercommunication.
There may be but one diaphragm, or there may be several of them, that is, at different points.
They are found mainly in the rectum.
When they occur in the small intestines, death results at a more or less early period. ^
Case 13. M. G., a medical officer in the French service, was always constipated from birth. He ate largely, but seldom passed a stool oftener than once in two months, and his abdo- men assumed a large size. At the age of forty-two his con- stipation was usually prolonged to three or four months. In 1806, after medicines had been taken to procure a stool which had not been passed for upward of four months, abundant evacuations continued for nine days, and contained the stones of raisins taken twelve months before ; but the constipation returned. In 1809 the enlarged abdomen became painful, vom- iting supervened, and he died at the age of fifty-four, having seldom through life passed more than four or five stools in the year.
On opening the abdomen, a fibrous partition was found that obstructed the rectum, about an inch from the anus. Imme- diately above this partition the rectum was so enormously dilated as to fill all the pelvis and nearly all the abdomen. The enormous cloaca contained thirty kilogrammes of brown-
1 See Part II.
CHRONIC CONSTIPATION
79
ish black and very offensive faeces. Its inner surface presented gangrenous and ulcerated patches. The lowest part of the colon was enlarged to the size of the stomach, which latter, with the small intestines, liver, etc., appeared diminished in volume and capacity by the pressure of the distended rectum. ^
Case 14. Quain, Disease of the Rectum, 1854, under the head of "Impaction of Fseces," describes the case of a man aged forty, who died with a large accumulation of fsecal matter which was evidently due to the presence of two crescent-shaped shelves of mucous membrane, one attached opposite the prostate, the other about four inches higher up. Each of these was more than an inch in breadth; the circular muscular fibres fully entered them and the longitudinal layer dipped in slightly at their base. Kohlrausch describes a similar case.^
B. Essential Primary Atrophy of the Large Bowel
Congenital Arrest of Development of the Muscular Apparatus of the Bowel
NothnageP describes a condition of atrophy of the muscles of the large bowel which he regards as a con- genital hypoplasia. This condition, which may be present in individuals with an otherwise excellent muscular de- velopment, is generally connected with a condition of chronic constipation. The patients in whom the condi- tion was noted had all stated, and their statements were confirmed by careful observation, that they went a greater or lesser number of days without an evacuation.
^ Kenauldin, Dictionnaire des Sciences Medic, 1813, Vol. VI., p. 257. Copland, Dictionary of Medicine.
2 Kelsey, Disease of the Rectum. Kohlrausch, Anatomie u. Physioloo-. der Beckenorgane, Leipzig, 1854.
3 Beitrage zur Physiologie u. Pathologie des Darmes, Berlin, 1884.
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CONSTIPATION IN ADULTS
C. Dislocation of the Bowels. Enteroptosis ^
The intestines may be dislocated, i.e. pushed out of their normal position. The small intestines may be forced down fcom the abdominal into the pelvic cavity, and
in their descent will inevitably compel the descent of the stomach. The large bowel may be dis- located in its vari- ous sections. The most common form of dislocation is downward, — en- teroptosis. The part said to be most lia- ble to be thus af- fected is the right colic flexure (j^ea;i<ra colica dextra) with the transverse colon next in the order of frequency. From what I have seen, I am inclined to be-
(From Eosenheim.) C, Cacum ; S, Sigmoid flexure. The bowel is inflated.
lieve that the reverse is true ; that the transverse colon is the part most frequently forced out of its normal posi-
1 Cxlenard, Lyon Medical, Tome XLVIII., No. 13 et seq. Cuilleret, fitude Clinique sur I'Enteroptose. Gaz. des Hopitaux, September 22, 1888, and No. 105, 1889. Pourcelet, De I'Enteroptose, Paris, 1889.
CHRONIC CONSTIPATION
81
tion, and that the right colic Hexure is generally but secondarily involved. The views of Glenard, upholding the former position, are based mainly upon the theoreti-
(From Rosenheim.)
F.il, Riglit colic flexure pushed down and over to the navel ; C.t, Transverse colon ;
jL, Liver ; M, Stomach.
cal consideration that the right flexure is but loosely attached and rather mobile. However, be this as it may, it is the dislocation of the transverse colon that has for us clinically the greatest interest.
82 CONSTIPATION IN ADULTS
According to the extent of its depression, the transverse colon will i3resent changes in its configuration. If it be but little depressed, it may have the form of an " M," whilst if the fall has been very, great, it may present itself to us in the shape of a " U " or a " V." ^ When the colon is increased in length, as occasionally occurs, numerous abnormal twists and flexures are formed which, taking sometimes an upward turn, push up the stomach and the parts above it.^
The etiological factors that have been invoked for the production of this condition are numerous. Leaving out of consideration the rather few cases that are congenital, it may be said that all those conditions that tend to relax the tone of the abdominal walls and of the intestines are the most fruitful sources of intestinal dislocation. It is most frequently seen in women in whom, as a result of numerous pregnancies and subsequent neglect of the hygiene of the abdomen, the abdominal parietes have become flabby, relaxed, even to the extent of a pendu- lous belly. In the few cases that have come under my observation this was the natural history. This is gen- erally admitted. Atonic conditions of the intestines and abdominal parietes after prolonged ailments, as typhoid fever, rapid emaciation, sometimes constipation of pro- longed duration, with great overfilling of these parts of the large bowel,^ lead to enteroptosis. Other causes are tight lacing, trauma, acute inflammatory disease of the peritoneum.
1 See history of Case 1, reported by William Levitt. Treves, Intestinal Obstruction, p. 124.
Rosenheim, loc. cit. 8 Treves, Intestinal Obstruction.
CHRONIC CONSTIPATION
83
This condition can be recognized in only one way, and that is by inflating the bowel with air or gas by means of a balloon or siphon (it is not always necessary to clear out the bowels before resorting to this procedure ; accu- mulation of fseces does not diminish its effectiveness^), and noting the contour of the bowel as outlined upon the abdomen. Normally the transverse colon is found between the xiphoid cartilage and the umbilicus (males), or at the umbilicus or a line or two below it (females) ; in enteroptosis it will be found below these points, more or less according to the extent of the dislocation. In one case that came under my notice, the transverse colon was found outlined at the level of the symphysis pubis.
Enteroptosis is always attended with constipation ; or if the coprostasis was originally the etiological factor or pre-existent, it is very much aggravated thereby. Krez- calls particular attention to this feature. Of the five female patients with enteroptosis coming under his observation, four had suffered for a long time with most obstinate constipation, whilst the remaining one had constipation and diarrhoea alternately. In my experience (six cases), constipation was always present.
The obstinacy of the constipation, or its aggravation, is due to the fact that the colon is bent upon itself in various ways. Although it is true, as Ewald ^ says, that under ordinary conditions this would not constitute a hindrance, as can be readily seen in the laboratory with what force and steadiness the faecal bolus is driven for-
^ Ewald, Berliner Jclin. Wochenschrift, 1890.
2 Muenchener mediziniscke Wochenschrift, 1892, No. 35.
^ Loc. cit.
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CONSTIPATION IN ADULTS
ward on its journey to expulsion, nevertheless, it does form an obstacle here, for the reason that the vigor in- herent in the muscles of the gut is markedly diminished, and the powerful aid supplied by a tense abdominal wall, the abdominal pressure {Baiichjwesse), is wanting, as a consideration of the etiological factors will show.
It is possible that exceptionally we may have produced as the result of the dislocation such marked contracture in the calibre of the transverse colon as to make it more like a cord, corde colique transverse, as Glenard ^ calls it ; but that it occurs in any way with the frequency he would have us believe is open to great doubt. It is not possible that such a marked change in the appearance of a prominent and exposed portion of the intestine should have escaped the attention of the many great anatomists and pathologists in their studies upon the human body.
This point is of great importance from the standpoint of prognosis. The evils of enteroptosis can, as is generally admitted, be in a great measure remedied ; but we are absolutely powerless against an enterostenosis, against a contraction of almost the whole length of the transverse colon.
Gruber described a dislocation to the right, of the sigmoid flexure, with enormous enlargement thereof. It was a post-mortem observation, the cadaver being that of a robust man. The abdominal cavity presented all the evidences of a long-extinguished peritonitis. The flexure lay in the fossa and in the right iliac region, and in the boundaries between the epigastric and the meso-
1 Loc. cit.
CHRONIC CONSTIPATION
85
gastric regions as far as the left hypochondrium. The jejnno-ileuni lay to the left of it, and downward, in the abdominal and pelvic cavities.\
\
•■'J
colol^'fsTg'Sefure""' S' ?V^^'T= ^f-^ing' colon ; o, Transverse tion nf f ho 1 "e^ure. a, Shank of the colon ; p, Shank of the rectum + Spp
tion of the large omentum that has become adherent to the • '
anterior abdominal wall.
^ Virchow's ArcMv, Vol. 56, p. 432.
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CONSTIPATION IN ADULTS
"The sigmoid flexure proved thus to be an enormously lengthened section of the bowel, 47 cm. in length, the shanks (^SchenkeV) of which are united by a long, 39 cm., but, as already stated, not broad mesocolon, and therefore they lie in closest apposition when they are in a distended state. The length of tube of both is 1 m. 22 to 38 cm. ; the width of the colon shank (the part which connects the flexure with the descending colon), increasing somewhat from below upward, is 6.3 to 7.4 cm. : the abnormal width of the rectal shank (the part connecting the flexure with the rectum) at the " S-like " curved descending portion 10.3 cm. in two directions; at the transition into the transversely placed initial section 6.5 and 8 cm., and at this last part 11.7 and 18 cm. respectively, in tAvo directions."
Section IV. Chronic Constipation from Impaired Physiological Function
By impairment of physiological function we understand ivfo very different conditions ; namely :
1. Perverted action.
2. Imperfect performance of physiological function.
It is only to this category of constipation, and more particularly to the last subdivision thereof, that the term Habitual Constipation can be properly applied, for it is only under such conditions that a person may be consti- pated for a long time, and still retain a fair condition of health.
CHAPTER VIII
PERVERTED ACTION; SPASTIC CONSTIPATION
1. Enterospasm
It has already been stated in the chapter on the physi- ology of intestinal movement that normally the circular and longitudinal muscular fibres contract alternately ; in this way the chymus is held fast, and not allowed to retrograde ; then the section of bowel is shortened, and it is pushed onward. Under the influence, however, of an abnormal stimulus, the physiological order may be perverted, in that the circular and longitudinal muscular fibres contract at the same time, synchronously and spas- modically, and all further movement on the part of the bowel, of the chymus, or of the residual and excrementi- tious matter, is inhibited. Moreover, as a result of this spasmodic contraction, the calibre of the bowels is greatly reduced, at times almost to the size of a lead-pencil.
This perversion of physiological action, the spasm of the intestinal muscles, enterospasm, may be general, i.e. involve the whole intestinal tract, from the duodenum to the rectum, or it may be partial, limited to a section more or less large thereof. It is general in basilar men- mgitis, in some of the pathological processes producing pressure upon the pons or the medulla oblongata, in saturnine intoxication. It is partial in colic, etc.
87
88
CONSTIPATION IN ADULTS
The partial is much more frequent than the general, and is most frequently located in the large bowel. ^
Leaving out of consideration the grave pathological conditions in which it is general, enterospasm occurs most frequently in gastric and intestinal indigestions ; in con- gestions and in catarrhal inflammations of the intestinal mucous membrane; it is of almost constant occurrence in colitis. More rarely does it present itself as a pure neurosis, as in enteralgia, or as one of the manifestations of hysteria or of neurasthenia.^
In rare instances it may be observed as one of the phenomena of tabes dorsalis (crises enteriques^), even though the crises gastriques be wanting.
The constipation that thus results is known as spastic constijoation.
In the majority of instances the constipation is but a secondary matter, as can be readily seen from the fore- going, that does not call for any special intervention, for a special therapy ; that yields or disappears upon the proper treatment of the pathological conditions of which it is one of the consequences.
As an idiopathic affection, if such an expression be permitted of the condition under consideration, it is of very rare occurrence, and is always associated with neuras- thenia or hysteria, even though their more characteristic features be in abeyance. In the unbalanced condition of the nervous system that is the chief characteristic of the morbid states just named, even an ordinary stimulus
1 Rosenheim, Pathol, u. Therap. der Krankh. des Darmes, 1893.
2 Kaczorowski, Deutsche medic. Wochensckrift, 1882, No. 1. 8 Rosenthal, Magenneurosen u. Magencatarrh.
PERVERTED ACTION; SPASTIC CONSTIPATION 89
that would otherwise have done no more than excite normal peristalsis may provoke an enterospasm.
Symptomatology. — In general enterospasm the abdo- men presents a characteristic appearance; it is sunken in, the walls are flattened down, and it has a scaphoid, a boat-like, shape, as is very well seen in basilar meningitis and in saturnine intoxication. Although in intestinal inanition the belly is also very much sunken in, it has not the boat-like appearance, nor is the sinking in, the flattening down, so marked as in general enterospasm, where the calibre of the intestines is reduced almost to a minimum. Partial enterospasm, such as is specially referred to here, does not cause any change in the con- figuration of the belly. The fceces, when the stool is had, pass in the form of cylinders of very small calibre, from that of a lead-pencil to that of a thin finger, of greater or lesser length ; these may be followed by cylinders of much greater circumference, or the whole stool may come in thin cylinders. Or the faeces may be discharged in the form of scibala of greater or lesser size ; but this last stool is in no way characteristic. Altogether, the quantity evacuated is insufficient.
A symptom that may or may not be present is pain. According to Rosenheim, pain is of frequent occurrence. It may be in any part of the abdomen, but is usually located about the navel, or in the left lower section of the abdomen. It is described as a pressing, a drawing together. Fleiner, in his article, does not make mention of pain. In the very few cases, within the limitations set down here, that have come under my observation, there was no pain, only a feeling as if a cord were drawn
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CONSTIPATION IN ADULTS
rather tightly across the abdomen; a sort of cincture feeling, but differing from that of tabes in that it was felt only anteriorly (not completely around), and mainly in the locality of the transverse colon, in the region between the epigastrium and the navel.
There is really but one characteristic feature, and that is the small-calibred cylinders of the stool.
If the whole evacuation be in this form, and continue to be so, then organic stenosis of the intestine must be excluded before the case can be set down as one of enterospasm.
2. Enterospasm and Atony
Partial enterospasm may be associated with atony of the intestinal muscles. Under these conditions, the sec- tion of bowel above the seat of the spasmodic contraction becomes distended with residual or faecal matters and with gas.^
3. Spasmodic Stricture of the Rectum
A spasmodic contraction of the rectum has been de- scribed, with obstinate constipation as one of the attendant phenomena. According to O'Beirne,^ it is the uppermost part or annulus of this section of the intestine that is usually the seat of the stricture. It is of exceedingly rare occurrence, so rare, indeed, that some excellent authorities either deny its existence absolutely, or ignore it in toto
1 Diseases of the Intestine and Peritoneum, 1879 (Reynold's System of Medicine). Article " Enteralgia." Rosenheim, loc. cit. Fleiner, ^er/iner klin. Wochenschrift, January 16, 1893. Cherchewski, Revue de Medic, October and December, 1883.
2 New Views on the Process of Defecation, etc., 1834.
PERVERTED ACTION; SPASTIC CONSTIPATION 91
in their writings.^ It is conceivable, however, and this the more so as the occurrence of partial enterospasm is generally admitted, that in hysterical and neurasthenic states, or under the influence of certain pathological con- ditions to be named further on, a spasmodic action of the muscles of the rectum might be provoked. The state- ments of Mayo,^ Ball, and the most recent observations of Kelsey,^ seem to confirm this view.
Symptomatology. — The constipation is rather of the acute character. The abdomen is very much distended with fasces and gas. There is a great deal of straining at stool, and much suffering with it. A bougie, or rectal tube, introduced for the purpose of examination, will meet with so much resistance that frequently a degree of force will be required to overcome it that might, under other conditions, prove rather dangerous to the patient.^ If the stricture is located lower down, near the anus, the finger introduced will be tightly grasped by the spasmodi- cally contracting muscle.''
4. Spasmodic Contraction of the Sphincter of the Anus (without Fissure). Irritable Sphincter
Much more frequently than the rectum the sphincter of the anus may be the seat of the partial enterospasm. It becomes then so firmly contracted that defecation is almost impossible.
1 Van B uren, Lectures on the Diseases of the Rectum. Curling, The Diseases of the Rectum. Mathews, Diseases of the Rectum, 1893.
2 Mayo on the Rectum (quoted in Pniitt's Surgery).
» Kelsey, Diseases of tlie Rectum and Anus, New York, 1890.
* O'Beirne, loc. cit.
* Kelsey, loc. cit.
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CONSTIPATION IN ADULTS
It may be a manifestation of an hysteria, or of a neurasthenia, but is most commonly seen in cases of sexual neurasthenia, dependent upon morbid states of the sexual organs. The obstinate constipation so frequently associated with spermatorrhea is undoubtedly very often thus produced.
An enlarged prostatic gland, or an inflammatory con- dition of that organ, may give rise to a spasmodic contraction of the rectum or anus. An inflamed or irritable urethra may likewise do so. In females, a spasmodic contraction of the sphincter may present it- self in connection with chronic ailments of the genital organs.
Symptomatology. — The chief symptom is the contrac- tion of the sphincter, which at times is so great that it is only with difficulty and by the use of some force that the examining finger can be made to pass, and then not with- out considerable pain to the patient. The examining fin- ger is tightly grasped by the spasmodically contracted sphincter. Occasionally (it might be said frequently) the patient has great pain at the end of the evacuation (ob- tained by means of purgatives or clysters) produced by the spasmodic closure of the sphincter.
In very severe cases, with almost tetanic spasm, the fceces occasionally have a very peculiar appearance ; they are flattened out, ribbon-like.^
Other symptoms are : more or less uneasiness about the anus, which is most marked when sitting, and least when lying down ; a feeling of fulness in the perineum ; irritabil- ity of the bladder, as shown by the frequent micturition
1 Henoch, Die Unterleibskraukheiten, 1863.
PERVERTED ACTION; SPASTIC CONSTIPATION
93
which, sometimes, is attended by a smarting or burning in the urethra.
The constipation is very obstinate ; I believe, however, that it is not the sphincter alone that is responsible there- for, but that, by reflex irritation from the sphincter, a nar- rowing of the rectum, and a shutting off of the opening of the sigmoid flexure or a constriction of the annulus of the rectum, as O'Beirne describes it, is provoked.'
Schroeder van der Kolk held that the habitual obstipation of the alienated arose from a spastic contraction of the descending colon inhibiting the onward passage of fsecal matter. From this point of view he devised his pills for the treatment of the same ; viz. small doses of extractum aloes aquosum, and still smaller doses of the tartrate of antimony.
This opinion was combated by Griesinger upon various grounds. Latterly, Professor Rudolph Arndt,^ in an article upon this subject, upholds the views of Van der Kolk that spasm is the cause of the constipation, though the same need not necessarily be limited to the colon descendeus.
^ Van Burea, Lectures upon the Diseases of the Rectum. Rosenheim, loc. cit. Goodel^ Journal of the Americ. Medical Associat., 1888, latter half, p. 15. A. Peyer, Die nervosen Affectionen des Davmes. Wiener Klinik, Heft 1, 1893.
2 Deutsche medic. Wochenschrifl, 1881, No. 29.
CHAPTER IX
IMPERFECT PERFORMANCE OF PHYSIOLOGICAL FUNCTION
Atony of the Intestine [JDarmatonie). Causes and their
Mode of Action
By far the greatest number of the cases of habitual constipation that come under our observation are due to an imperfect performance of physiological function on the part of the intestines, more especially of the large bowel. ^
Atony [atonia, infirmitas et remissio virium) means a loss of vigor, a loss of normal muscular force ; and loss of this means an incapability to perform normal func- tion. It means also a loss of normal irritability ; a lethar- gic state seems to come over the muscle, and it responds but slowly and imperfectly to the normal stimulus.
Muscle and muscular power keep pace with the amount of work they are called upon to perform. With active exercise of the part or organ, within physiological limits, the volume and tone of the muscle is preserved and kept at the normal ; with scant use or disuse it loses both in volume and vigor. The bowels form no exception to this rule. Where from any cause the exercise of their muscu- lar apparatus is diminished, it loses in vigor, it loses in normal irritability, and, without doubt, to a certain extent, in volume.
1 See also Fleiner, loc. cit. Rosenheim, loc. cit.
94
performancp: of physiological function 95
The consequence of this atony of the muscular appa- ratus of the large bowel is an inability to perform normal function, namely, the expulsion of the residual material, and constipation results.
But it has still another effect. Judging by analogy, by what we see in the salivary gland, it may be assumed that the action of the muciparous glands is stinmlated and the mucus secreted by them and discharged into the follicles is pressed out from them into the canal, where it fulfils its function, by the muscular contractions. Where, how- ever, these contractions are wanting in so marked a meas- ure as in atony, there will then be lack of stimulation, and, consequently, lack of secretion ; moreover, much of what is secreted will be retained in the follicles, distend them, and become a source of irritation. This retention is still further favored by the sealing up, as it were, of the mouths of the follicles by the stagnating fjBcal matter. Thus the dryness of the fasces, their hardness, and, per- haps, also the occurrence of ulcers in certain cases of marked constipation, wherein the question has arisen, " Which has preceded ?" can be accounted for.
The causes that lead to such impairment are :
1. Neglect to attend to the Calls of Nature. — From the press of occupation, by reason of the etiquette of our day, from lack of opportunity at the proper time (such as is provided in most of the large cities of Europe), the call of nature is disobeyed. This does not happen once, but is of frequent, of daily occurrence, and, as a result thereof, a toleration is established both on the part of the mucous membrane and of the terminal nerve filaments, and that which was regarded by nature as a foreign body to be
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CONSTIPATION IN ADULTS
expelled at the proper time, is now permitted to remain, to take up a permanent abode, as it were.
This is so well-known a fact within the experience of the generality of mankind, that it really needs no further elucidation. It is fully explained by what has been said previously upon the physiology of defecation, and upon the well-known facility with which nature becomes habit- uated to the presence of extraneous matters and influences.
2. The Pernicious Habit of Reading at Stool. — A great many good people have become and will become consti- pated, and cause themselves much annoyance and much useless expenditure of money by their attempts to do two things at one and the same time ; namely, to empty their bowels and fill their heads.
Cloacina is very exacting, and demands the full concen- tration of the mind upon the duties there to be performed. It has already been set forth in a preceding chapter how the mind regulates, in a great measure, this important function, and in that light the deleteriousness of attempt- ing to read during the process of defecation is clearly ap- parent. The inhibiting influence of the will being diverted from the spinal centre controlling the sphincter, the latter contracts at once, and, in consequence thereof, the rectum falls together, the opening of the sigmoid flexure is shut off, and perhaps itself narrowed, and further descent of fsecal matter prevented. A sort of retroperistaltic wave sets in, which may even carry back faeces that have already partly descended into the annulus of the rectum.
I have had this controlling influence of the mind demon- strated to me, and have demonstrated it, in another way : When the call of nature came, some work or some reading
PERFORMANCE OF PHYSIOLOGICAL FUNCTION 97
that was of interest was taken up, the mind plunged in medias res, and the call of nature left unheeded. Very soon, as the mind became absorbed in the work, the desire passed away. Then the thoughts would be again turned to the bowels and to the necessity of having a stool ; a response, in the form of a call of nature, would soon follow; at first slight, then more forcible, until, on the way to the lavatory, the call became imperative and urgent.
3. Food Defective in Residual Matter. — It has already been shown that a certain amount of residual matter, as coarse vegetable fibre, etc., is necessary for the excitation of the large bowel to peristalsis. A food too rich in nutritive material, and very poor in residual matter, will cause constipation. The peristalsis of the large bowel is already normally slow, and if there be a lack of stimulus or irritation, it will cease almost altogether. In this country this factor stands out very prominently. Our food, the food of the people, is too rich in nutritive mate- rial, and too poor in residual matter : large quantities of meats, eggs, bread almost entirely starch, potatoes, and but little of the vegetables rich in cellulose. Moreover, great numbers of people, either from laziness, or from force of circumstances, live almost entirely upon prepared concen- trated foods. The fruits that are eaten, as apples, pears, are deprived, before being eaten, of that portion which cries out to the bowel, like the policeman to the habitue of the street corner, " Move on."
The influence of the character of the food upon peristalsis is very well illustrated by the following, from veterinary medi- cuie. Attention is Called in the Ma</asinf. die gesammte Thier-
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CONSTIPATION IN ADULTS
heilkunde, XXXIL, p. 326,i to the fact that the machine-cut straw fed to animals, being cut too short, was in many cases the apparent cause of obstinate constipation, and frequently of death to the animals ; it became packed so tightly in different parts of the large bowel, the caecum, the transverse colon, the sigmoid flexure, that no medicament was able to move it on.
Food Deficient in Fats. — We occasionally meet with persons who take almost no fat at all with theh food; their milk is skimmed, butter they do not eat, and what- ever of fat there may be about their meats they cut away. They do this from false hygienic considerations, as to the preservation of the complexion, as to the main- tenance of their digestive powers, or from bad early training.
The residue of unassimilated fat and the fat detritus are, no doubt, one of the many factors that excite the peristalsis of the bowels, both large and small ; they are also an important constituent of the faecal matter, tending to keep it soft. A deficiency thereof is therefore apt to manifest itself by constipation and an induration of the faeces even to such an extent that its discharge through the anus may be attended with considerable pain.^
4. The Habit of Abstaining from Cold Water. — Many people, from crude notions, or through bad advice, abstain altogether from the use of cold water ; whatever of fluids they take is in the shape of warm decoctions.
Besides that these decoctions are in the majority of instances detrimental by the astringent properties they possess (decoctions of tea, of coffee ^), they are deleterious
^ Schmidt's Jahrbiicher, Vol. 137.
2 See Part II., " Constipation in Infants," Chapter IV.
8 I refer here only to the abuse of these articles.
PERFORMANCE OF PHYSIOLOGICAL FUNCTION 99
by their warmth alone (hot water, infusions of camomile, of anise, etc.). The constant application of this warmth tends to establish a condition of turgidity of the circula- tion in the intestines, impairing thereby the functioning of the secreting organs located in the mucous membrane, and obtunding the normal sensibility of its nerve fila- ments. It has a relaxing effect on the muscle.
Cold water has a general stimulating, tonifying, effect on the intestinal canal both directly and reflexly, upon the circulation, upon the nerve filaments, and upon the muscular tunics of the intestine, as all who have ever experienced a cramp colic after a very cold drink will testify to.
5. Want of Sufficient Physical Exercise. — That a cer- tain amount of physical exercise is necessary for the well-being of the. human body is a well-demonstrated fact, patent to all. Exercise stimulates all the physiological processes going on within the organism ; the circulation is hastened, the respiration is activated so that there is a greater exhalation of carbonic acid and increased inhala- tion of oxygen ; destructive metamorphosis becomes more rapid, and the results thereof are more quickly excreted.-^ As a consequence, the muscles and other structures are invigorated, acquire greater power, and thus become im- portant factors in the better execution of physiological processes.
Lack of sufficient exercise naturally entails the reverse of all this. Torpidity is the most marked feature, then, of the corporeal mechanism ; the circulation becomes sluggish, the temperature is lowered, the respiration, i.e.
^ Carpenter, Human Physiology. Landois, Human Physiology.
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CONSTIPATION IN ADULTS
oxygenation, is retarded, and carbonic acid accumulates and tends to further deepen the lethargy, and destructive metamorphosis is slowed. As a result of this torpidity, the muscles become relaxed and weak.
A great many people, however, do not get the necessary amount of physical exercise, either from indolent habits, as we often see it among the more fortunately situated class, and particularly among the female portion thereof, or by reason of a confining, more especially, a sitting occupation.
In so far as our special subject is concerned, it can be readily understood how, from the torpidity of the muscles, from the want of the stimulating influence of vigorous oxygenation,^ and from the increase of carbonic acid, all the consequences of their inactivity, such persons become constipated, even obstinately constipated,
It is also readily understood how prolonged confinement in badly ventilated rooms (working therein — even when the work is of rather an active character — and sleeping therein) causes constipation.^
6. Muscular Weakness of the Abdominal Walls. — This may, in some rare instances, arise from some defect of muscular development; most generally it is due to neg- lect of the proper measures after parturition.
A moderate degree of relaxation of the abdominal wall will not, in my opinion, — and herein I agree with Rosen- heim,— produce, 7:>er se, constipation; but combined with some of the other etiological influences named, it is certainly most potent in developing a coprostasis, and m
1 See the chapter on the "Physiology of Intestinal Movement."
2 See also Birch, Constipated Bowels, 1868.
PERFORMANCE OF PHYSIOLOGICAL FUNCTION 101
maintaining it. In its severest form, the pendulous belly, it is not only the sole cause of the constipation, but it is the most difficult, and not infrequently the insuperable, obstacle to the recovery of the patient.
7. Obesity. — Large deposits of fat about the abdomi- nal parietes and the intestines tend to impairment of normal muscular vigor, to atony, to constipation.
8. Prolonged Mental Work; Prolonged Mental Worry; General Depressing Influences, lower the irritability of the nervous system, and, in consequence, all the physiological functions are very markedly slowed.
9. Bad Teeth, or Want of Teeth, prevent perfect masti- cation, and compel either the deglutition of badly masti- cated food, which will subsequently develop a dyspepsia, or a resort to a pap and slop diet.
10. Old Age. — Besides the feebleness of muscle, the torpidity of the secreting organs incident to this epoch of life, the lack, in many cases, of good masticating organs, the bland character of the food, the want of necessary exercise, are important factors in perpetuating a condition of constipation.
I have not counted among the etiological factors the habit of pill-taking, which many authors hold as the chief cause of the evil, for the reason that I do not believe that it is so.
My experience, both in hospital and private practice, has demonstrated to me that "purgative-taking" is not the fons et origo of constipation ; rather the reverse, pur- gative-taking is the residt of constipation. That it finally aggravates the derangement, — of this there can be no doubt ; the excessive irritation of the purgative exhausts
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the normal irritability of the intestinal tract, especially when the drug is so frequently repeated and in ever- increasing doses ; a condition of over-fatigue, of exhaus- tion of the muscle, is established.
An over-indulgence in very coarse vegetable foods may produce the same result.' The great abundance of coarse residual matter causes an excessive irritation of the bowel just as do purgatives, and constipation, as a result of the exhaustion of the normal irritability, follows.
TTie prolonged use of warm or lukeivarm or emollient injections is likewise injurious.^ Their mode of action is readily understood. They cause turgescence of the parts, they enervate the muscle, they dull the normal irritability of nerve and muscle.
Among the incidental causes of constipation, and to whicli Birch 3 has already called attention, is the inadvertent con- sumption of certain derivatives of the mineral kingdom, whicli tend to dry up the secretions of the bowels, and to lump and harden the faeces. These are alum, the salts of lime, the salts of lead, iron, and copper.
Alum is found in adulterated flour. It is said to be fre- quently used by millers to give their flour a lustrous white- ness. It is a constituent of many baking powders, and thus gets into the bread and other dietary preparations that we con- sume. Lime salts: The sulphate of lime is said to be used extensively in the preparation of various confections. The drinking water may be highly impregnated with the salts of lime, as we find in the well water of many country districts. Birch states that he has seen a number of cases of constipation so produced. In young infants it may be the lime-water added
1 Rosenheim, loc. cit. Boas, Diiit u. Wegweiser f. Darinleidende.
2 See Nouveau Dictiounaire de Med. et de Chirurg. Pratique. Article "Constipation."
8 Birch, Constipated Bowels, 1868.
PERFORMANCE OF PHYSIOLOGICAL FUNCTION 103
to their milk. Salts of lead : Various cheap candies are colored with the red oxide or yellow chromate of lead. Numerous cases of constipation with colic, in children, from the consump- tion of such candies have been reported. Even graver con- sequences, intoxication and death, have resulted therefrom. This offence against public health merits the earnest attention of the authorities. The drinking water may be impregnated with lead from the pipes through which it is conducted. Copper we get with our pickles and various other like condi- ments. Iron : The prolonged use of preparations of iron may lead to constipation. Drinking water rich in iron, as the waters of St. Louis, Michigan, may have the same effect.
Mode of Action :
Though some of the etiological factors just named act chiefly upon the mucous membrane, obtunding its sensi- bility and the sensibility of its nerve filaments (as the neglect of the calls of nature, habitual use of food con- taining but little residual matter, adulterated food as just referred to), whilst others act primarily upon the muscular structures (as indolent habits, want of sufficient exercise, insufficient oxygenation), and others again upon the nerves governing the process of evacuation (as read- ing at stool, prolonged mental worry or occupation), nev- ertheless, the effect of all these factors is, in reality, one and the same, to wit, a loss of normal tone, of normal vigor, in the muscular coats of the intestinal tract, — an atony of the bowel. It can be readily understood that an atony could not occur, that the muscles could not fall into this lethargic state, if the mucous membrane, if the ulti- mate nerve filaments, retained their normal sensitiveness.
It is generally admitted that, as has been indicated at the outset of this chapter, the abnormal — it cannot be
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called pathological — condition present in the great ma- jority of cases of habitual constipation is an atony of the intestine}
An atonic condition of the intestine is not infrequently one of the sequelae of the infectious diseases that are attended with abundant discharges from the bowels, as typhoid fever, dysen- tery, cholera. Here also the atony is, in greater part, a conse- quence of the preceding hyper-irritation.
Atony of the intestine is one of the prominent features of chlorosis ; so prominent, indeed, that Sir Andrew Clark was disposed to look upon the disease as a copraemia. However this may be, this much can be said, that, the disease once devel- oped, all the conditions thereof tend to make the coprostasis more obstinate. It is a generally admitted fact (and one that I hold as of the greatest importance) that there is insufficient oxygenation. 2 The stomach is very much disturbed ; the appe- tite is poor and perverted ; there is a distaste for the grosser kinds of foods, and what nutriment is taken is in concentrated form, and even of this but little is consumed. There is a feel- ing of languor, of fatigue, which opposes all exercise and active exertion ; a loss of tone in muscle, shared by both stomach and bowels.^
1 Fleiner, loc. cit. Rosenheim, loc. cit.
2 Osier, Principles and Practice of Medicine. Rosenbach, O., Enstehung u. Hygienische Behandlung der Bleichsucht.
3 Rosenheim, loc. cit.
CHAPTER X
SYMPTOMATOLOGY
Constipation has but few characteristic symptoms ; when it has been said that the faecal evacuations are retarded beyond the normal period, that the stool is hard and dry, and that the person is unable to have a full and free discharge without having recourse to a purgative, its special features have been described.
It is true, as has been pointed out,^ that nature will, after a longer or shorter period of time, — from four days to three weeks, — make an effort to dislodge the accumulated material. It is, however, generally unsuc- cessful, always so when the constipation is due to atony, in that only a very few hard scibala, which had been pushed far down into the rectum by the vis a tergo and had set up an unusual irritation about the sphincter, are discharged, whilst the bowel above still remains loaded ; and even this does not occur frequently, once the constipation has become a habit. It is correct, therefore, to count among the characteristic features of this derangement the neces- sity of a purgative for the production of a full and free evacuation.
In addition to these special features, we have certain other phenomena, some of a local, some of a more general character, that present themselves to us in constipation.
1 Kaczorowski, Deutsche mediz. Wochenschrifl, 1882.
105
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CONSTIPATION IN ADULTS
General Symptoms. — The tongue is coated ; usually it is a thick, white fur ; not infrequently, a yellowish one. The breath is offensive. The appetite is poor, maybe 7iil; sometimes dyspeptic phenomena, as eructations, heavi- ness after eating, — even after small meals, — nausea, are noted. Occasionally there is a disgust for food ; the per- son cannot look at it. A bad taste in the mouth.
Headache is of frequent occurrence. It is really rather a feeling of fulness, of heaviness, of the whole head, or more particularly of the frontal portion, than a pain.
Vertigo, rushes of blood to the head, are complained of. In one case of prolonged constipation, due to anal fissure (which is reported more in detail further on), I saw 2^Tofound stiqoor, so profound indeed that it was only with great difficulty that the patient could be aroused, and then he would murmur only a few unintelligible words, and relapse into his former state. This stupor had lasted, at the time I saw him, for over three weeks.
The perturbation may be more general. It may be a feeling of malaise, of hebetude, that renders the person incapable of doing any work. It may be a hypochondri- acal condition that has supervened ; the person is morose, moody, and preoccupied with himself. Again, it may manifest itself in a marked irritability; he (or she) is quarrelsome ; nothing is right, nothing is proper, and he (or she) has a grievance against the whole of creation. I once knew a very eloquent professor who suffered from chronic constipation in whom this feature stood out so prominently as to become quickly known to the students, and they could tell at once, when he appeared on the rostrum for his lecture, by his manner and look, whether
SYMPTOMATOLOGY
107
he had had his clyster and an ample evacuation that morning, or whether his duties had kept him therefrom. Rosenheim' mentions alternate sensations of heat and cold. I have not observed this except in neurasthenics, and have ascribed it rather to an aggravation of the neurasthenia caused by constipation, than to the constipation itself.
Senator ^ holds that the phenomena are due to intoxication by sulphuretted hydrogen gas (SHg), and bases his belief upon a case that came under his observation. At a later period, in a discussion of dyscrasias, he reaffirmed this view.^ To this it may be opposed that the case upon which this view is mainly based could very possibly have been, and the whole history points very much that way, one of ilio-csecal intussusception. Such a state is, of course, altogether different in its effects upon the intestinal processes, and no conclusion could be drawn therefrom that would be valid for other conditions. Moreover, there is a possibility, even a probability, that in the case re- ferred to a considerable quantity of sulphuretted matter was introduced from without. Besides all this, the investigations of Ruge,^ of Novack and Brautigam,^ as already mentioned by Rosenheim, very clearly controvert such an opinion. These investigators have found that ordinarily the quantity of SH^ in the admixture of intestinal gases is less than 0.1 per cent, rarely more, even when the f seces are long retained, and such a quantity is much too small to cause phenomena of intoxication."
^ Loc. cit.
2 Senator, " Ueber einen Fall von Hydrothionamie," etc., Berlin, klinische Wochenschrift, 1868, p. 254.
3 Zeitschrifl f. klinische Mediz., Bd. VII.
* Ruge, Wien. Silzumjsherichte d. Akad. der Wissenschaften, 1862, p. 729. Foster, Human Physiology.
^ Nowack u. Briiutigain, Muenchener mediz. Wochenschrift, 1890.
* The experiments of Bergeon (Nouveau Traitement cies Affections des Voies Respiratoires, etc., par les Injections Rectales Gazeuses, V. Morel, Paris, 1886) and others {Medical News, Phila., 1887), in the treatment of tuberculosis, demonstrate that large quantities of SH,, can be introduced into the intestinal tract without causing the least systemic disturbance.
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The explanation of Rosenheim ^ that they are caused by auj?- meiited putrefaction in the albuminoids, presents as many difficulties. 2
My own opinion is that they are based upon disturbances of the nervous, circulatory, and glandular systems of the intestinal tract. All of these must suffer, more or less, in constipation, from the filling up of the bowel and the pressure necessarily exerted by the hardened masses. It may also be possible that the diffusion of CO2 into the intestinal canal 3 is interfered with and its consequent accumulation in the blood may con- tribute to the production of the perturbations described.* We see similar phenomena in persons who are very much confined to their room, in whom there is an insufficient oxygenation, and consequently an increase of COg (beyond the normal limit) in the system.
As to the loss of appetite alone, there is but little diffi- culty in its explanation. The atony of the intestinal mus- cles soon involves those of the stomach. The movements of this latter organ are very much slowed, and conse- quently the chymus is retained therein for a much longer time. The chemismus itself does not seem to be impaired.
1 Log. cit., p. 502.
2 The investigations of Von Pfungen (Zeitschrift f. klinische Mediz., Bd. XXI.) and others have all been made on persons in whom grave or- ganic disease, as peritonitis, myelitis, existed, and in whom, therefore, all the bio-chemical processes must have been seriously affected. It may be justly questioned whether what holds good under those conditions will apply to constipation without the co-existence of organic disease; with an otherwise normal condition of the digestive tract, stomach included. Von Pfungen himself there says that where the secretion of HCl in the gastric juice is not diminished, the putrefactive processes occurring in the albuminoid mat- ters in the large bowel are at about the normal. See "Auto-intoxication," in following chapter.
* Normally a certain amount of C0„ is diffused from the blood into the intestinal tract. See chapter " Flatus."
* See Senator, Berlin, klinische Wochenschrift, loc. cit. Hoppe-Seyler, Physiol. Chemie.
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In the intestinal canal the digestive process is not interfered with ; it is possible that there may be a greater splitting lip of the albuminoids in the large bowel.^
How the bad breath is produced, it is difficult to say. Whether it be that some of the inhaled air that is carried into the stomach passes thence into the intestinal canal, and becoming charged there with the odors from the fjBces, or with volatile gases, is carried into the circula- tion and excreted through the lungs, or that these odors or gases pass upwards and through the stomach, and mingle with the expired air, is something yet to be determined.
Local Symptoms. — Flatulence : ^ a sense of distention ; a feeling of fulness, of heaviness in the belly. The abdo- men may be distended symmetrically, or only in part thereof. Rolling and purring noises in the bowels. No tenderness of the abdomen. Colics not infrequent ; more rare in habitual constipation due to atony. Stitches in the side, under the liver or under the spleen ; in the back, in the lumbar region, sometimes as high up as the inferior angle of the scapula, which cause the persons considerable suffering and much uneasiness as to the state of their liver or of their kidneys. The pains are transitory ; there is an interval of rest of longer or shorter duration ; then the person feels something shooting up his bowels into the locality named, and the pains at once follow ; they are wandering, being now on one side, then on the other. They are more severe when the person sits or lies down, and are relieved by standing or walking.
^ Von Pfungen.
2 Accumulation of flatus.
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All these phenomena are provoked hy the distention of a loop or loops of intestine by accumulated flatus and the irregular peristalsis thus therein excited. A full discharge of wind per rectum will quickly effect their disappearance.
Itching at the Anns. — I have known constipated persons in whom the call of nature was expressed in an itching about the anus, which grew more intense the longer the evacuation was delayed, and disappeared at once with the discharge. Some of my patients informed me that they would have no rest until they had taken an active purga- tive, and thoroughly cleansed their bowels.
If the abdominal parietes be not too thick, the large bowel can be very readily palpated. If a condition of constipation exists, we will find more or less large faecal masses accumulated therein, which can be readily felt, and can be demonstrated to be faecal matter by the ease with which they are broken up with the fingers. They are most numerous and most readily felt in the descending colon and the sigmoid flexure ; in cases of long standing, they can be found almost always in the transverse, and even in the upper portion of the ascending colon.
The faeces are harder and drier than normal ; frequently hard and dry, and are usually evacuated in the form of scibala, varying in size from a hickory-nut to a horse- chestnut ; two to three scibala may be agglutinated to- gether, and thus form larger masses. I have seen them in the form of cylinders, and so hard that it required an axe to break them. They vary in color from a very dark brown to a black. There is nothing remarkable about the odor.
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The special features of enterospasm have been already described.
As in all other ailments, so also here the symptoms given may be all present or the greatest part may be wanting (and this is not infrequently the case once the person has become habituated to the constipation), and between these two extremes we have the various and numerous gradations.
CHAPTER XI
DIAGNOSIS; PROGNOSIS
Diagnosis — Examination
The diagnosis alone of constipation is not a difficult matter. The patient himself will tell us that he is con- stipated, and when he has described to us the period of time intervening between one evacuation and the other, and when he has informed us that his bowels do not move without a purgative, without an injection, we can have no further doubts. Some difficulty may be encountered when we are confronted with that somewhat paradoxical condi- tion where the patient complains of diarrhoea, whilst in fact he is constipated. However, even here we can readily acquire certainty. A careful examination of the abdo- men, a careful examination of the large bowel, of the rectum, will disclose to us, if constipation be present, large masses of hardened faeces.
The principal point in diagnosis is to differentiate whether the constipation that we are called upon to treat is that form which can be called idiopathic — habitual con- stipation — or whether it is produced by one of the many pathological processes that may give rise thereto. This must be done by exclusion. For this purpose we must acquire a full history of the patient ; we must carefully inspect his appearance and that of his body; we must
112
DIAGNOSIS; PROGNOSIS
113
examine carefully his abdomen, his bowels, his rectum, and finally the feeces must be carefully studied, both macroscopically and microscopically.
By the inquiry into his history, we acquire valuable data as to the mode of onset of the constipation, the age at which it first manifested itself, and its duration. We learn whether at any time previous there was pain with the stool, whether there is pain with the stool now, before or after (ulcer, spasmus, fissure) ; whether the stools were admixed with recognizable blood; whether they were black and tarry (hasmorrhage of the bowel, high up) ; whether they contained or still contain large or small quantities of mucus, on top or closely intermixed.
We learn therefrom whether there is any reason to sus- pect tubercle. It is very important to know as to the probability of a tuberculous condition, for tuberculous stricture ^ is a possible factor that must not be overlooked in the process of exclusion. We may get data as to the family history that will indicate to us whether malignant disease should be suspected. We will learn whether the patient has ever had strangulated hernia ; whether he has ever had dysentery, and possibly a subsequent contraction of the lumen of a section of the tube ; ^ whether he has had any of the manifestations of syphilitic infection, — and syphilis may give rise to a stricture in the bowel.
We will learn whether the patient has had sexual ail- ments, as gonorrhoea, gleet, spermatorrhoea ; whether he is addicted to evil practices, etc., all of which are frequent
^ Treves, Intestinal Obstruction, p. 259. Koenig, Deutsche Zeitsckr. f. Chirurcjie, 1892.
^ Treves, loc. cit., pp. 255-26.S.
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causes, direct or indirect, of obstipation.' We will gather indications as to whether the patient is a neurasthenic or an hysterical individual or not. Finally, we learn whether a foreign body should be suspected or not.
General inspection of the patient, of his body, will give weight to what we learn from his history as to tubercle, as to cancer. It will inform us whether the liver, the kidneys, the heart, must be looked to.
It will thus greatly facilitate our examination.
Local inspection of the abdomen will inform us whether it is normal or not ; whether it is distended, and if so, whether it is symmetrically distended. It will furnish us valuable information as to the state of the portal circula- tion, and thus inform us as to the condition of the liver.
By a careful examination of the abdomen, we will be able to decide the question of effusions, of gaseous dis- tention of the bowels, of tumors of the abdomen. We will discover the state of the bowels, of the peritoneum, whether they are normal or not. We will learn the con- dition of the abdominal walls, whether they have their natural firmness, or whether they are relaxed or flabby.
An examination of the large gut will at once disclose whether it is full or empty ; whether it has its normal lo- cation. We will learn as to pathological processes within or around it ; as to growths or foreign bodies.
A careful examination of the rectum will at once inform us as to the presence or absence of accumulations of faeces, of hsemorrhoids, of polypi, of ulcers, of fissures, of malig-
1 A. Peyer, Die Nervosen Affectionen des Darraes. Wiener Klinik, Jan- uary, 1893. Lowenfeld, Die Nervosen Stoerungen Sexuellen Ursprungs, 1891.
f
DIAGNOSIS; PROGNOSIS
115
nant disease, of tuberculous, syphilitic, or dysenteric strict- ure, of shelves of mucous membrane, of foreign bodies ; will at once inform us as to the condition of the mucous membrane and parts below, whether they are normal or not.
Of the greatest importance are the macroscopic and mi- croscopic examinations of the fseces. By the macroscopic examination we note the general appearance of the stool, whether it is scibalous or of cylindrical form ; its consist- ency, whether very hard, very dry, or only moderately so. We see the color thereof, whether brown, or black, or clay- colored. We note whether mucus is present in abnormal quantities or not. We discover the odor, and thus learn whether abnormal putrefactive processes are going on within the intestinal tract or not. We receive some indi- cations upon the questions of enterospasm.
A microscopic examination will furnish useful infor- mation as to the food of the person ; whether it is too concentrated or not ; whether it contains too much indi- gestible matter; will inform us as to the presence therein of foreign matters, as blood, epithelium, mucus, and helminthes.
The difficulty in diagnosis encountered is chiefly that connected with the question of stricture ; firstly, as to the presence or absence of a stricture higher up when the rectum is found free ; secondly, if a stricture is present, is it an organic or a spasmodic stricture ; thirdly, if organic, is it interstitial or extraneous (contraction of the inflam- matory products of the serous coat; shrinking of the mesentery).^
^ Treves, Intestinal Obstruction.
Il
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CONSTIPATION IN ADULTS
Strictures, interstitial, comparatively of not infrequent occur- rence, may result from any form of ulcerative disease, and may occur in any part of the intestinal tract. Those of the small intestines are generally located in the ileum, in the middle and lower portions thereof. They' are much rarer than those of the large bowel, as 1 : 5 or 1 : 6. Of the large bowel (in fact, of the whole intestinal tract), the rectum is the most frequent seat of stricture ; the sigmoid flexure is next after the rectum the most frequent site ; then come, in the order named, the colon ascendens, the left colic flexure {flexura coli sinistra}, the right colic flexure (flexura coli dextra). The caecum is rarely ever thus affected.^
When the abdominal walls are not too thick or too rigid, the large bowel can be readily palpated through them.
Procedure. — The patient (if a child, the bladder must be previously emptied) is placed on a firm couch in the horizontal position, with the head slightly elevated (by a cushion or by the head-piece usually found on couches), with the lower ex- tremities extended. The examiner places himself to the right of the patient ; he can seat himself, which is more convenient, on the couch beside him.
To facilitate reaching the bowel, the patient is told to keep his belly drawn in ; this will shorten the antero-posterior diameter of the abdominal cavity, bring the parts more closely together and thus more within our reach.
To obviate the reaction, the muscular contraction and the consequent rigidity, which almost always follows when pres- sure is made upon the abdominal parietes, various expedients may be resorted to :
(a) The patient is impressed with the necessity of keeping his belly loose, relaxed.
(6) He is told to breathe deeply ; this has a very relaxing
1 Kelsey, loc. cit. Mathews, Diseases of the Rectum. Van Bureii, Lectures upon the Diseas. of the Rectum.
DIAGNOSIS; PROGNOSIS
117
eifect upon the abdominal parietes. Furthermore, the deep inspirations, by causing deep descent of the diaphragm, will depress the bowel, especially the csecum, 2 to 4 cm., and thus enable us to locate the latter more readily.
(c) The left hand is placed upon the abdomen, over the linea alba, with the larger part of the hand towards the left ; pressure is there made, and all the reaction concentrated under- neath it. The region to the right can now be palpated ; no reaction on this side now following as long as the pressure with the left is continued.
Obrastzow uses the outer and thenar surfaces of the thumb of the left hand, and makes pressure as described.
Or the left hand can be placed as described above, and firm pressure with a pushing away, to the left, motion made ; mus- cular contraction will be impossible. This is the expedient that I prefer.
In cases of great rigidity of the abdominal walls, I have found it necessary to have the lower extremities flexed ; how- ever, only to a moderate extent, i.e. so that the knees were just somewhat elevated above the plane of the abdomen. This will usually effect a sufficient relaxation without being in any way a hindrance to the examination.
Percussion. — I always make it a point to precede the palpa- tion with percussion. Beginning in the right inguinal region and running obliquely upward and outward, we have the caecum ; upwards to the under border of the liver, the ascend- ing colon, then to the right as far as the spleen, the transverse colon; here we must make our percussion more carefully, to differentiate the stomach from the colon. Then again down- ward to the crest of the ilium, the descending colon, and downward and inward in the left fossa iliaca to near the symphysis pubis, we have the sigmoid flexure.
From percussion we will derive much valuable informa- tion as to the locality of certain special sections of the bowel, and also whether these sections are more or less distended or not. It will be a sort of outline for us on which to palpate.
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CONSTIPATION IN ADULTS
Palpation. — The CEecum and the sigmoid flexure may be palpated aftei- the fashion of the stomach ; the four fingers of the right hand, extended, are brought down perpendicularly on the part, with a light but firm pressure, raised and brouglit down again, until the whole section has been gone over. I prefer to palpate the csecum in the same way as I do other parts of the large bowel, to wit : the four fingers of the right hand are placed where the inner or upper border of the ctecum is supposed to lie, whilst the thumb is placed towards the lower or outer border ; gradually the fingers are pressed doAvn more deeply, moved about and approached slowly until the part desired is felt between them or in the hollow of the hand.
For the ascending colon the fingers (of the left hand) are placed on the right flank. The four fingers, extended, are towards the back, whilst the thumb is forward and upward. The fingers are pressed in gradually deeper and deeper, other parts are pushed aside, and finally the ascending colon is grasped.
The transverse colon is palpated in the same way, Avith this difference only, that both hands are used, one on either side of the umbilicus. The fingers are placed toward the upper, the thumb toward the lower border. The same movement already described is made ; the fingers are pressed in deeply, gradually, and slowly, the parts are rolled between the thumb and fingers until finally the bowel is grasped. Once seized, we can follow it for a certain distance, three to four fingers' breadth, to either side.i
To palpate the sigmoid flexure, the examiner can remam m the position originally taken to the right of the patient ; then in palpating after the last method, he will place the fingers towards the outer or lower border, against the ilium, and the thumb along the upper border. I have often found it conven- ient to change the position, to place myself to the left of the patient, facing his feet. This gives me command of the right hand in the same position as for the ctecum.
We can facilitate our examination by drawing on the abdo- men or by keeping in mind the following lines :
1 Obrastzow. See furtlier on.
DIAGNOSIS; PROGNOSIS
119
1. From the umbilicus to the right anterior superior spine of the ilium.
2. From the umbilicus to the left anterior superior spine of the ilium. These are the Unece spino-umbilicalis.
3. From the right to the left anterior superior spine of the ilium. This is the linea inter spinalis.
The exact point at which to palpate for the various sections of the large bowel are shown in the following figure.
a, Left linea spino-umbilicalis; b, Right linea spino-umbilicalis; e, Linea inter- sptnalis; c, Csecum and ascending colon; d, Descending colon and sigmoid flexure.
Caecum. — For the csecum we will begin on the right side, on the linea interspinalis upward along to the linea spino- umbilicalis ; here we will palpate from below upward, i.e. from the crest of the ilium toward the umbilicus. Ordinarily, ac- cording to Obrastzow, the csecum is found in the outer or in the middle third of the right linea spino-umbilicalis — removed about 5 cm. from the spine of the ilium, and not reaching the linea interspinalis.
In cases of constipation the csecum may be filled to almost any extent with fsecal matter and gases, and is, therefore, more
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CONSTIPATION IN ADULTS
or less dilated. It may extend upward to the anterior third of the linea spino-umbilicalis and down to the linea interspinalis and beyond. In one case of enormous accumulation of faecal matter, grape-seeds, grape-skins, etc., the caicum extended from the anterior superior spine of the ilium, to the left, to within 2 cm. of the linea alba; downward it filled out the wliole inguinal region, reaching to the symphysis pubis.
In another case, a patient aged seventy, suffering with chronic cystitis, greatly emaciated, and in whom the large bowel was very much distended with gas and stood out promi- nently upon the abdomen, the caecum looked like a large bologna sausage; it extended from below the linea interspinalis up and somewhat beyond the linea spino-umbilicalis, and from the anterior superior spine of the ilium, half-way into the middle third of the linea spino-umbilicalis.
The transverse colon will be found between the umbilicus and a line drawn transversely across along the under border of the costal arches. In males it will usually be found from 1 to 3 cm. above the umbilicus ; in females it will be on a line running through the umbilicus, or 1 to 2 cm. beneath it.
There are of course many incidents and accidents that may tend to change its position, either depressing or elevating it, as has already been described in the chapter on " Enteroptosis." All these things must be taken into account in the history of the patient, and borne in mind when the physical examination is made.
The sigmoid flexure will be generally found at a distance of 3 to 5 cm. from the left anterior superior spine of the ilium toward the umbilicus on the left linea spino-umbilicalis, and crossing, also, downward, the linea interspinalis.
In cases of constipation it may be distended to almost any extent. It may reach from the crest to the supra-pubic space and from the anterior superior spine to the umbilicus, depend- ing upon the length of time the constipation has lasted, and the extent of accumulation allowed.
Sounds. — The cajcum may not give forth any particular sound on palpation ; usually, however, a rumbling or purring noise produced by the dislocation of flatus is heard.
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In the transverse colon we may occasionally have a similar rumbling sound.
In the flexura coli sinistra, where we may have marked tym- panitic resonance on percussion, we may get a rumbling sound, as loud, almost, as that of the csecum and from the same cause.
In two cases I heard a splashing noise ; but I am not positive that it was produced in the bowel. In the one case the stomach gave a like splashing noise on palpation. No exact differential diagnosis could be made on this point, as the patients would not, under any circumstances, consent to the introduction of the stomach tube. However, from the location where the sound was obtained, far over toward the spleen, and judging from the point at which the gastric splashing sound was ob- tained in the other case, I believe that the splashing was really produced in the flexure, and was not merely a sound made in the stomach and conveyed from thence.
Over the sigmoid flexure we may get the same rumbling, purring sounds or none.^
In all cases much depends upon the individual tendency to the production of flatus, which is more marked in older persons than in the young, and greater in those with depressed vitality than in persons in robust health.
Having finished the palpation of the large bowel, we will palpate the rest of the abdomen, after the manner already described, causing the fingers to penetrate as deeply as pos- sible, but without causing the patient any pain.
By palpation we will learn much as to the state of the bowel, whether it is empty or full; whether it contains much of hardened faeces or not. We will also learn whether there are any growths within the intes- tinal canal, or extraneous to it and pressing upon it. In females, we will also learn much as to the condition
1 Obrastzow, "Zur physikalischen Untersiichung d. Magens und Darius," DeutHch. Archivf. klin. Medicin, Bd. 43. " Ueber d. physikal. Untersuchung des Darms," Archivf. VerdauungskrankJieiten, Bd. 1.
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of the genital tract, whether the cause of the obstipation lies therein or not.
Great assistance in examining the large bowel will be afforded us by inflation.' We can insufflate it with carbonic acid gas from an ordinary siphon of charged waters/ or we can inflate it with atmospheric air by means of a balloon.
Arrangement of Apparatus for Inflation by Means of the Siphon (of
Carbonated Water).
The gas of one siphon of carbonated water (Seltzer, Vichy), amounting ordinarily to li to 2 litres, more than suffices to dis- tend the large bowel.
1 Senn, Experimental Surgery, 1889. Behrens, Ueber den Werth der kuenstl. Auftreibung d. Dickdarmes mit Gase u. Fluessigkeiten Goettingen, 1886. Danisch, Ueber d. Werth d. k. Auftreibung d. Darmes d. Gase, Ber- UnerMin.Wochenschrift,\Qm. Rosenheim, loc cit. «-Des
2 Schnetter, Deut^ches Archivf. kUnische Medicin, Bd. 34. Fougeray, Des Injections Rectale Gazeuses," Gazette des Hopitaux, 1886, p. 1116.
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According to the more exact investigation of Damsch, one litre of air is all that is usually required.
The bowel will be outlined to us very clearly upon the abdomen, and we will, moreover, have a good percussion surface. (By a careful percussion after inflation, we may be able to locate either a foreign body or a tumor or an induration that might not be otherwise perceptible.)
By inflation we will very readily learn whether the gut occupies its normal location, or whether a dislocation of a section thereof has occurred.
Arrangement of Apparatus fob Inflation by Means of the Double Balloon.
We will learn the size of the large bowel, whether it is normal or not ; we will be able to see, to a consider- able extent, the configuration of the sigmoid flexure, and thus learn whether it is of normal or abnormal conforma- tion.
By inflation we can distinguish whether certain abnor- mal growths that we may discover by abdominal palpation are of the intestines or not ; moreover, we will learn to what organ they do belong. By the distention of the bowels with gas the tumor is gradually pushed away, and it always retreats in the direction in which the organ of
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which it is a part is located. Tlius, tumors of the kidney will be pushed back, behind, and become imperceptible; of the liver, to the right, into the hepatic region ; of the spleen, to the left, into the left hypochondrium. Tumors of the stomach will be pushed upwards.
By this method we may be able to discover a stricture that could not be found otherwise. The air will pene- trate the bowel up to the point of stricture, dilate it, and make its outlines distinct on the abdominal parietes ; whilst above the stricture, the part not dilating to that extent, its contour will not be so clearly outlined on the abdominal surface.
Auscultation can be combined with the insufflation. The entrance of air into the free and dilating portion will be accompanied by a loud, hissing sound, which can be readily heard by the aid of the stethoscope ; whilst beyond the point of stricture the sound will be barely perceptible. Moreover, on percussion over the region of the large gut, as already described, we will find that the part this side of the stricture, freely insufflated, will give a marked tympanitic sound ; whilst above the seat of the stricture the sound will, in comparison, be flat.
If we attempt to inflate the portion beyond the seat of stricture, we will find it attended with considerable difficulty ; it will require a much longer time, and then the distention will not be so marked as that of the portion below it.^
If it be a question of stricture, it is perhaps better to empty the bowel thoroughly, by means of a purge or large clyster, before inflating.
1 Rosenheim, loc. cit.
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For the examiikation of the rectum, the patient should be placed in Sim's position, on the left side, with knees well drawn up. The buttocks being held well apart, the anus and exterior surroundings are carefully in- spected.
With the well-oiled finger carefully introduced, the rectum can be explored through the whole of its lower four or five inches, and its condition learned (htemor- rhoids, contraction, etc.). Much may be learned, more- over, by this examination, as to the condition of the prostate, of the posterior urethra, of the ureters, of the ovaries, of the uterus, — all of which are at times impor- tant factors in the production of constipation.
It may be necessary to supplement such an examination with an ocular inspection. This will be greatly favored by the use of a head-mirror, or of an electric forehead- lamp.
As to the further details regarding the diagnostic points of stricture of the various portions of the intestinal tract and the various methods of examining the rectum, and the instruments employed therefor, the reader is referred to the works of Van Buren, Kelsey, Mathews, Cripps, and to the article -of Dr. H. A. Kelly,' in the Annals of Surgery, 1895. For special information with reference to the diagnosis of abdominal tumors, the works of the great gynecologists, the larger treatises upon sur- gery, and the lectures upon abdominal tumors lately delivered by Dr. William Osier in Johns Hopkins Hospital may be consulted.
1 " \ New Method of P]xainination and Treatment of the Diseases of the Rectum and Sigmoid Flexure," Annals of Sur (/en/, A-pril, 1895.
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Peristaltic movements may be visible sometimes upon the surface of the belly, when the abdominal walls are very thin and relaxed. Abnormally strong peristaltic movements so visible, is one of the features of all forms of stricture. They begin in the part above the point of contraction ; they may be either slow, vermicular, now gently rising, now disappearing, or they may manifest themselves as irregular, violent move- ments, attended with considerable suffering. The loop of intestine promenaded across the abdomen may be so much dilated that the small intestine may be mistaken for the large bowel, and the latter for the stomach.
Rosenheim^ attaches much importance to this phenomenon and says : " In doubtful cases, visibility of the peristalsis will speak in favor of an already long-existing obstacle."
Stool. — Cylinders of small calibre, of the size of a pencil, or of the small finger, are held to indicate a spas- modic narrowing of the lumen of the bowel. They are also seen in the stools of persons having a tendency to diarrhoea, in whom the faeces contain a superabundance of water.^ Tape-like bands denote a stricture of the rectum.^ The absence of these forms does not, however, ^jer se, exclude the existence of a stricture, spasmodic or organic.
Stool in the form of scibala, hard and dry, always points to atony of the intestine.
The indications afforded by color as to the presence of blood have been already mentioned. The absence of bile is indicated by the peculiar color of the stool ; it is an ashy-gray. Such stool is also very sticky, adhering like tar to the vessel and has usually a frightful odor (wanting in vegetarians).
1 Loc. cit.
2 Rosenheim, loc. cit.
8 Kelsey, Mathews, Ball.
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127
Mucus in considerable quantity upon the stool indi- cates a hypersecretion from the rectum. Though this is frequently due to a catarrhal condition of the mucous membrane, it does not necessarily always indicate this. It may result from a temporary irritation of the muci- parous follicles produced by some transitory cause, as prolonged pressure of irritating particles in the faeces. Considerable mucus intermixed closely with the faecal matter indicates a catarrhal condition located rather higher up, in the small intestine, the caecum, the ascend- ing or transverse colon.
Microscopic Examination of the Faeces/
Haematine, the coloring matter of the blood (recognized by formation of Teichmann's crystals), and crystals of
hamatoidin indicate the presence of blood, and point to a haemorrhagic effusion into the bowel at a more or less early date.
Pus, when recognizable, indicates the presence of an abscess, or of an ulcerative process in the intestine, or
Crystals of HiEMAToroiN from F^CKS. (Jaksch.)
Teichmann'i
's HjEmin Crystals. {Jaksch.)
^ See chapter " Faeces.
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the effusion of pus from an abscess exterior to it into the intestine.
Pus and hcematoidin crystals point to cancerous disease. Occasionally the characteristic structural elements of this morbid process can be discovered in the fjeces.
Charcot-Leyden crystals will many times denote the presence of helminthes.' Leichtenstern has found them also in the faeces of phthisical persons.^
The ova of various intestinal worms may be thus discovered.
Furthermore, and of importance for the special condi- tion under consideration, such examination will disclose to us whether the person has sufficient residual matter in his aliment, or whether it is defective therein.
For the better examination of the faeces both macroscopically and microscopically, the following method is recommended by Dr. Herz : A small quantity of the faeces taken from diverse portions of the stool is rubbed up in a mortar with some water. This addition of water is necessary with all stools, even with thin ones, for true watery stools are rather infre- quent, and in the former the mucous element having a specific gravity nearly like that of the corpuscular neutralizes the in- fluence of the centrifuge. A five per cent solution of carbolic acid answers very well for this purpose, as it disinfects the excrement and destroys or masks to a great extent the dis- agreeable and often nauseating odor. When thoroughly rubbed up, the mass is subjected to the action of the centrifugal ma- chine. As each of the constituent elements of the faeces has its particular specific gravity, the mass under the influence of the machine must dissolve itself into a number of separate and distinct layers.
1 Rosenheim, loc. cit.
2 Deutsche medicinische Wochenschrift, 1886. Jaksch, Klinische Diagiiostik.
Microscopic Appearance of some Constipated Faeces Ji Case of Four Year's Duration
I
DIAGNOSIS; PROGNOSIS
129
On the surface there is a layer of turbid fluid, swarming with bacteria. Beneath this are the mighty layers of the vege- table constituent, the cellulose. Hereupon follows a black ring made up almost entirely of residual muscular fibre. Beneath this, and forming about one-eighth of the whole column, we find a number of narrow layers which contain the least numer- ous, but diagnostically the most important elements, separated from each other, as round cells, Clostridia, starch, etc.
Thus already by mere inspection we may form an idea as to the composition of the fseces.
For microscopic examination a portion is removed from the individual layer with a long pointed pipette. ^
When the micro-organisms are the main objects of examina- tion, the electrolytic action of the galvanic current may be employed for sedimentation, after the method of Winkler and Fisher. Two plain iron wires are connected with a battery {they worked with two carbon-zinc elements, about 200 milli- amperes) and their free ends introduced into the vessel con- taining the fluid to be sedimented. Care must be had that the free ends do not come in contact with each other and so form a short-circuit. This can be readily avoided by keeping them apart by means of a small block of wood ; even a large pledget of cotton wool will answer. Five to fifteen minutes, according to the strength of the current employed, suffice for the sedi- mentation. Under the electrolytic influence there is, as is well known, a formation of gas ; gas bubbles form a layer of froth in the neck of the flask, and beneath this is a turbid layer con- taining the micro-organisms, and from this a portion is taken up by means of a fine pipette.
For' this process, the faeces are prepared as already described for the procedure of Herz. Winkler and Fisher maintain that, furthermore, amoeba are much more readily recognized, as the current stimulates them into active movement.^
For other and further details on this very interesting sub- ject, consult V. Jaksch, Klinische Diagnostik, Rosenheim, Darm- krankheiten.
1 Centrnlblatlf. innere Medicin, 1892, p. 883.
2 Centralblatlf. innere Medicin, No. 1, 1893.
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The diagnosis of idiopathic constipation having been thus arrived at, Ave will differentiate the aiojiic from the spastic form by the history and symptoms already given in preceding chapters.
The atonic condition of the bowel can be demonstrated in a more positive manner, just as it is done for the stomach ; namely, by the splashing Qplaetsehern') sound. It has been found by Boas,i and confirmed by the investigations of Friedenwald,^ that in normal persons 500 to 600, and even 700 c. cm., of water must be thrown into the bowel before the splashing sound can be obtained ; while in an atonic state of the intestine the splash- ing and succussion sound can be heard after 300 to 400 c. cm. have been allowed to flow in.
To bring out this phenomenon, the bowels having been pre- viously well moved, warm water (90° to 100° F.) is allowed to flow slowly into the bowel ; otherwise, if there be much force to the injection, the fluid may pass beyond the ileo-csecal valve and give rise to erroneous conclusions. At 300 c. cm. the flow is stopped and the bowel palpated ; if the splashing sound is not heard, we proceed on to 350 to 400 c. cm., and so on.
In some few cases this symptom may fail us altogether, and still atony be present.
As to the differentiation between acquired atony and congenital atrophy of the intestinal muscles, we must be guided by the history of the case. The constipation due to the latter condition dates from a very early period of life without any appreciable cause, as catarrh, etc., there- for. Furthermore, as has been pointed out, there is in this condition rather a slowness of discharge than a con- stipation. On the whole, however, it may be said that congenital atrophy is exceedingly rare, and cannot be clearly recognized during life.
1 Personal communication.
2 "Atony of the Intestines," Medical Neivs, August 11, 1804.
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131
Prognosis
It is not at all a question as to life. This, as has been already stated at the outset, is not endangered by constipa- tion. Exceptionally, however, and it is well to remember this, a fatal result may follow. Death has occasionally resulted from ileus paralyticus,' and I myself saw a case, already once referred to here, in which, despite appar- ent recovery from the constipation, death from asthenia, undoubtedly a consequence of the prolonged retention of fsecal matters, ensued.
It is really only a question as to recovery. On this head it may be said that it is, as a rule, favorable. Al- most all cases, even when considerable dilatation or even hypertrophy of the bowel has already occurred,^ when properly managed, recover and resume a normal habit. The exceptions to the rule are these :
I. Where there is a marked dislocation of the bowel of long standing, the prognosis is doubtful.
II. When the abdominal walls are very flabby and re- laxed, when the belly is pendulous, so that the Bauch- presse, the pressure of the abdominal walls upon the gut, is lost, although much may be done by mechanical aids, it is, nevertheless, very doubtful whether a restoration to the normal can ever be effected.
III. Old people. Here, besides atony, we have a degen- eration, resulting from age and from the prolonged atony. There are, besides, other factors, which will be mentioned further on, that tend to make the prognosis unfavorable.
1 See also James T. Goodhart, M.D., in Trans. Clinical Society, London, Vol. XIV. A case of ulceration with hypertrophy and dilatation of colon, perforation, and peritonitis.
^ See following chapter.
CHAPTER XII
THE CONSEQUENCES OF CONSTIPATION
Though persons go through life constipated without suffering any serious derangement therefrom, it is none the less true that in many others it becomes the etiological factor, as has been well established by ample clinical observation, of various, and even very grave morbid processes.