by always placing it at this hour in a position favorable to and
suggestive of defecation. Dilating the sphincter at the same time with
the soap suppository or the small end of a Davidson's syringe, or just
touching the margins of the anus, will excite the necessary reflex
movement. If defecation is painful, examine the inner edge of the anus
for small cracks or for eczema ani.[52] Over-stretching the sphincter
with the finger in cases of rigid or spasmodic contractions will
sometimes produce permanent relief.
[Footnote 52: Betz, "Eczematous Proctitis," _Memorabilien_, iv., Dec.
28, 1859, S. 190.]
In children the question of diet is equally important. Most cases of
constipation in them originate in intestinal catarrh from improper diet
and over-feeding. Strict rules of diet should be rigidly enforced, and
each case receive special study in order to determine upon the best
dietary. The minutest details of the child's life, its habits and
surroundings, are to be controlled so as to secure the best possible
influences for health. Feeble development and muscular inertia must be
remedied by change of climate and tonics--iron, strychnia, and
cod-liver oil. When other methods fail to give early relief, a
purgative may be needed. Rhubarb, magnesia, calomel, Friedrichshall or
Hunyadi water, given in milk, the compound liquorice powder, the
compound anise {657} powder, are better than the more active
cathartics.[53] Habitual administration of laxatives to children ought
to be regarded as a confession that the case is incurable; it is a last
resort, for which necessity is the only argument.
[Footnote 53: The compound anise powder, a non-officinal preparation in
use in Washington, is a convenient form of administration: heavy
calcined magnesia, 360 grs.; rhubarb powdered, 180 grs.; oil of anise,
40 minims; stronger alcohol, one fluidrachm. The bicarbonate or fluid
magnesia is also a good preparation. Ringer knows nothing so effectual
in bringing back the proper consistence and yellow color to the motions
of children as podophyllin. Dissolve one grain of the resin in one
drachm of alcohol, and of this give one or two drops on a lump of sugar
twice or three times a day (_op. cit._, p. 458). Bouchut suggests the
same solution, with simple syrup as a menstruum.]
In old persons tonics should be combined with the laxatives, as
strychnia, iron, quinia, gentian with aloes, colocynth, rhubarb, or
podophyllin. The rectum should always be examined, as impacted fecal
masses will often be found there.
{658}
ENTERALGIA (INTESTINAL COLIC).
BY W. W. JOHNSTON, M.D.
SYNONYMS.--Enterodynia, Tormina, Colicodynia, Colalgia, Dolor colicus,
Passio colica, Spasmus intestinorum, Ileus spasmodicus, Spasmus
ventriculi, Neuralgia mesenterica; Spasm of the bowels, Cholick or
Cholick Colic, and Pain in the Belly; _Ger._, Das Banchgrimmem, Die
Kolik; _Fr._, La colique.
HISTORY.--Colic is described by Hippocrates.[1] He recommended the use
of emetics and gave other sound advice regarding the treatment of the
affection. Galen[2] administered sedatives, as opium and henbane, and
he advised them to be combined with carminatives. Aretæus[3] speaks of
the pain of colic extending to the back, limbs, and testicles, and also
states that when affecting the sides of the body it may be confounded
with pleurisy, hepatitis, or splenitis. Alexander[4] points out the
differential diagnosis of the disease and directs a proper course of
treatment. Cupping, friction of the extremities, and dry fomentations
were recommended by Celsus;[5] and internally he advocated a mixture of
poppy, anise, pepper, etc. Aëtius[6] describes the affection.
Serapion[7] and Avicenna[8] treated of colic more clearly than any
previous writers had done, and advised narcotics administered by the
mouth and rectum. Atony of the bowels is given as a cause of the
disease by Haly Abbas,[9] and Alsaharavius adds[10] to the etiology a
hot intemperament, indurated feces, and poisonous medicines. Rhazes[11]
directs the administration of emetics when the colic is due to
indigestion.
[Footnote 1: _De Affect._, xv.]
[Footnote 2: _De Med. Sec._, loc. ix.; iv., de loc. _Affect._, vi. 2.]
[Footnote 3: _Morb. Acut._, ii. 6; _Chron._, ii. 8.]
[Footnote 4: Lib. x. 1.]
[Footnote 5: _Medicina_, Libri octo, iv. 14.]
[Footnote 6: Lib. iii. 1, 29.]
[Footnote 7: iii. 32.]
[Footnote 8: iii. 16, 4.]
[Footnote 9: _Pract._, vii. 28.]
[Footnote 10: _Ibid._, xvii. 2, 12.]
[Footnote 11: Divis. 69.]
NATURE AND DEFINITION.--Enteralgia is the name given to intestinal pain
which is independent of indigestion and of inflammation or other
organic change in the wall of the bowel, and corresponds to gastralgia
and other visceral neuralgias. It involves the nerves which pass to the
intestine along the line of attachment of the mesentery, and which are
derived from the superior mesenteric plexus, with a prolongation from
the junction of the right pneumogastric nerve with the coeliac
plexus.[12]
[Footnote 12: The very extensive distribution of terminal
nerve-filaments in the intestine is an explanation of the frequency and
severity of attacks of intestinal pain. "We may form some estimate of
the extent to which the nervous system of the intestines is developed
from the fact that about one hundred ganglia belonging to the submucous
and over two thousand to the myenteric plexus are to be found in one
square inch of the intestine of the rabbit" (Frey, _Histology_, New
York, 1875, p. 493).]
{659} The pain of enteralgia is not spasmodic, and is not accompanied
by flatulence, borborygmi, or other signs of indigestion and gaseous
distension of the bowels.
Colic, on the other hand, applies to intestinal pain accompanied by
indigestion, distension of the bowel with gas, or the contact of
irritating ingesta. The pain is spasmodic, and is relieved by the
passage of gas and other contents from the bowel. The pain is due to
the local irritation of the richly-gangliated plexus of nerves seated
in the submucous layer and which extends from the pylorus to the anus.
At present enteralgia must be considered from its symptoms and from
post-mortem examinations as a pure neurosis of the sympathetic system.
Opportunities are rarely offered for studying the post-mortem
appearances of the disease, from the fact that when idiopathic it
seldom ends fatally. Out of forty-nine autopsies on patients who had
suffered from colic due to lead-poisoning, only one was found with any
change of the abdominal ganglia of the sympathetic. Ségoud found the
ganglia and some of the fibres of the sympathetic hypertrophied and
indurated,[13] and "in recent times Kussmaul and Maier have published
an example of sclerosis of the coeliac and superior cervical
ganglia."[14]
[Footnote 13: Ségoud, _Essai sur la Névralgie du Grand Sympathique_,
Paris, 1837.]
[Footnote 14: M. Rosenthal, "Diseases of the Nervous System," _Wood's
Library_, New York, 1879, vol. ii. p. 265.]
The pathology of enteralgia due to a vitiated state of the system, a
morbid condition of the tissues of the intestines, the presence of
irritating ingesta, or to reflexion from other organs, differs in no
wise from a neuralgia of other parts arising from constitutional,
local, or reflex causes. Pain will likewise manifest itself here in
consequence of deleterious substances circulating in the blood, as in
Bright's disease, rheumatism, gout, or lead-poisoning. The terminal
nerve-fibres of the intestines are irritated in attacks of colic by
substances or food within the alimentary canal; gases are generated
from the decomposition of the ingesta. The consequent dilatation of the
gut produces loss of tone and abolition of the contractile power of the
muscular coat. Constipation and pain from pressure exercised on the
neighboring nerves will be the result.
Obstinate constipation, and even symptoms resembling ileus, may arise
from a portion of the intestine thus distended becoming bent upon
itself, the sharp angular flexure interrupting or completely
obstructing the passage of the feces.[15]
[Footnote 15: F. H. Hamilton, _Med. Gaz._, New York, 1880, vii. p. 3.]
ETIOLOGY.--Enteralgia may be either idiopathic or symptomatic. The
causes can best be considered by dividing them into general and reflex.
Under the head of general causes may be mentioned an inherited neurotic
temperament, particularly in individuals of a hypochondriacal tendency.
Females are far more apt to suffer from this affection than males, on
account of their more impressionable nature and greater liability to
nervous diseases in general. Hereditary tendencies, overtaxing the
mental powers during the developmental period of youth, and later in
life excessive mental labor and anxiety of business affairs, are
causes. It may occur in the cachexia developed during the course of
many chronic diseases, as diarrhoea, rheumatism, gout, phthisis,
cancer, Bright's disease, etc. Various morbid conditions of the blood
are followed by {660} enteralgia, as anæmia arising from prolonged
lactation, masturbation, or venereal excesses, and the presence of
various blood-poisons, as syphilis, malaria, lead, copper, and arsenic.
Other causes are living in cold, damp climates, with sudden changes of
temperature and chilling of the body. Persons addicted to the use of
tobacco or alcohol and to dissipations of various kinds may become
predisposed to enteralgia. Idiosyncrasy is a predisposing cause.
Enteralgia is often secondary to ovarian, uterine, or other distant
disease. Also, owing to intimate sympathetic relations, pain is often
felt in the bowels as a result of disease situated in some of the solid
abdominal viscera, as the liver, spleen, and pancreas. In the same way,
organic affections of the brain and spinal cord, especially acute
myelitis and spinal sclerosis and lesions of the vertebral bones,
excite intestinal pain. Emotion may also bring it about. The
application of cold to the feet or catching cold in general is followed
by pain which is due to reflex influence.
There may be a predisposition to colic from hereditary influence and
the neurotic temperament. A feeble digestion is a source of constant
risk. Much of the pain occurring in the course of dysentery, catarrh of
the bowel, invagination, fecal impaction, and other structural
affections is of the nature of colic. The most frequent by far of the
local causes is the direct irritation of the terminal nerve-fibrils by
substances within the alimentary canal and by over-distension of the
bowel with contained gas. Some of these irritants are partly-digested
and indigestible articles of food; food taken cold or in excessive
quantity; the decomposition of food and consequent distension of the
bowel by gas. Acid drinks and alcohol have the same effect.
Constipation with scybalæ may produce colic in an otherwise healthy
person. A morbid state of the intestinal secretions, either as regards
quantity or quality, is said to have a like result, but this is a
doubtful cause. Foreign bodies within the canal, as fruit-stones,
various concretions, worms, and gall-stones if of large size, may
produce pain during their passage through the bowel. Cathartic
medicines may be enumerated as among the local causes, and also various
poisonous drugs. Lesions of any sort seated in the intestinal wall, as
ulcers and neoplasms, induce paroxysmal pains.
SYMPTOMS.--The pain of enteralgia occurs in attacks which come on
slowly and continue for a variable time--some hours or days. The pain
is situated about the umbilicus, and is relieved by deep pressure,
although at the same time there may be hyperæsthesia of the skin. The
intensity of suffering ranges from a dull heavy pain to one which is
acute and lancinating. Retraction of the abdomen is common, but there
may be tympanites. No signs of indigestion may appear, but eructations
of tasteless gas, or even borborygmi, may be complained of.
The duration of an attack of enteralgia is variable and depends to a
great extent upon the cause. Usually, when the symptoms are severe, the
duration is short. It may pass off in less than an hour, or a
succession of paroxysms continue to recur, and the attack will be kept
up for several days, weeks, or even a month. One seizure predisposes to
another, and each is liable to be more severe than its predecessor.
The malady may end gradually or as rapidly as it was ushered in.
Attacks are often mitigated, or even terminated, by the occurrence of
some other morbid condition--by a profuse sweat, the discharge of
lochia, {661} the menses, or some secretion which has been checked. The
development of rheumatism or gout may relieve it. Attacks often
terminate with vomiting, belching, and more especially with movements
of the bowels and discharge of flatus. A free emission of pale,
colorless urine is sometimes followed by relief. This occurs in
hysterical cases, and the disease is generally accompanied with some
uterine disorder and with tenderness along the spine.
The attack of intestinal colic may be developed suddenly and with full
intensity, or it may be preceded a short time, usually a few hours, and
rarely much longer, by prodromic symptoms. These are nausea, a
sensation of weight in the epigastrium, anorexia, eructations,
tympanites, rumbling, and slight griping pains. The patient is
irritable and restless, his bowels are usually confined, and urination
is often rendered painful by the distended bowels pressing upon the
bladder.
These symptoms, which are in truth but a part of the attack, being only
of a lower grade, increase in severity and the pain becomes more acute
and distinctly paroxysmal. It is of a sharp cutting, twisting, or most
frequently griping character, and is in the earlier part of the attack
usually referred to the umbilicus or to one of the iliac fossæ, and
sometimes radiating thence in different directions. Generally it
becomes concentrated about the umbilicus. The exacerbations of pain
vary in degree of severity, in duration, and in frequency of
recurrence, while the intervals may afford complete relief or merely a
remission of the acute suffering. The sufferer either lies quietly upon
his abdomen or upon one side or the other, with his body bent forward
and thighs flexed, or he is restless and writhes in pain, groaning and
crying out from the intensity of suffering. He may seek relief by
trying a variety of positions and by pressure applied with the hands or
some solid object against the abdomen. Anxiety and pain are depicted in
his features. His face and extremities are cool and covered with a
clammy sweat. The pulse is small, hard, and generally slower than
normal. Breathing is sometimes oppressed, as a result of spasmodic
contraction of the abdominal and thoracic muscles. Often the muscles of
the hands, calves of the legs, and the feet are similarly affected. The
tongue is moist and as a rule clean. The bowels are constipated--at
times so much so as to amount to obstruction--or, again, diarrhoea and
tenesmus may be present.
Other abdominal symptoms are nausea or vomiting, eructation of gas, and
borborygmi. Micturition is at times urgent and painful, and the
testicles are frequently retracted.
The abdomen is occasionally tender, but pressure generally affords
relief. It is distended with gas, especially over the large bowel.
Palpation often reveals lumps or knots situated within the abdominal
walls and due to spasmodic contraction of its muscles, particularly of
the recti. In thin persons the constricted and dilated coils of the
intestines can also be distinguished as nodular masses which rapidly
alter in shape and position.
The severity of attacks of colic varies from a few slight griping pains
felt at intervals to a seizure of such intensity that the patient
suffers agony and presents symptoms of an alarming nature. Fortunately,
these grave cases are comparatively seldom observed. In them the local
and general symptoms are aggravated. Pain is more intense and {662}
constant, having less marked intervals of relief, and the patient may
pass into collapse, with a small, rapid, and wavering pulse, restricted
respiration, shivering and chilliness, and a cool, clammy skin. The
abdomen is greatly distended; hiccough comes on, also stercoraceous
vomiting, tenesmus, and in the worst cases involuntary stools and
suppression of urine. Nervous symptoms have been observed, as dizziness
or fainting, and finally delirium and convulsions may end the scene.
VARIETIES.--Attention has been called to a distinct form of enteralgia
due to the effects of alcohol.[16] It affects steady drinkers, and is,
as a rule, met with only during the hot months. The presence of
undigested food within the alimentary canal or exposure to cold may act
as exciting causes of the disease. The development is usually gradual.
Dull pains, felt at first over the abdomen, become later more
continuous and fixed about the epigastrium or umbilicus. Sometimes they
are complained of more over the bladder. Bilious vomiting and hiccough
are prominent symptoms; the patient is thirsty, and the liquids taken
only promote vomiting; and the bowels are constipated. There is
restlessness, and sleep is obtained with difficulty. Paralysis at times
supervenes, and affects the lower as well as upper extremities. In the
worst cases delirium and even convulsions occur. The disease nearly
always ends in recovery in from three to ten days. Severe intestinal
and gastric pain occurs in opium-eaters, but especially in women who
use morphia in excess. The suffering is always greater when the opiate
is reduced, but can only be cured by breaking up the bad habit.
[Footnote 16: Colica bacchanalium, J. H. Claiborne, _Med. Monthly_, New
York, 1855, p. 227.]
A variety of colic which occurs epidemically[17] in some of the
inter-tropical countries has been studied and described by different
observers. It is known by various names, such as colique sèche; colique
végétale; rachialgie végétal; colic of Poitou, of Devonshire, of
Madrid, of Java, of Surinam; colique nérveuse; endémique des Pays
Chauds (Fonssagrives); endemic colic, dry colic, bilious colic, nervous
colic; girafy; dandy, etc. Ségoud called it a neurosis of the great
sympathetic, and attributed the disease to the effect of cold.[18] The
symptoms resemble, in many respects, those of lead colic, and at one
time they were erroneously considered identical with it.[19] Thompson
and Chisholm,[20] after an {663} experience with the disease in the
West Indies, assert that such is not the case. Epidemics which occurred
in Madrid and several of the Spanish provinces, and many hundred cases
witnessed among the French soldiers by other observers, were
ascertained not to be due to lead-poisoning.
[Footnote 17: Colique végétale, or endemic and epidemic colic, did not
escape the notice of the older writers. It is mentioned by Aretæus;
Paulus Ægineta describes an epidemic of the disease which extended
through Italy and a large part of the Roman empire, and he states that
attacks were often followed by paralysis. François Citois gives an
account of an epidemic which raged at Poitou in 1616. Monson Smith
described the disease in 1717. In 1724 it appeared in Devonshire,
England, and presented the characteristic symptoms and sequelæ. In more
recent times epidemics of the disease have occurred in nearly all the
countries of Europe. It prevailed in the northern part of France and in
Belgium from 1853 to 1859, inclusive. It has likewise visited the
Caribbee Isles, Cayenne, Guadaloupe, Madagascar, India, the West
Indies, some of the provinces of Spain, Java, the west coast of Africa,
the Antilles, Senegal, New Zealand, Brazil, and various other
localities. The disease occurs in all seasons, but is more prevalent in
summer and in the commencement of autumn.]
[Footnote 18: Ségoud, _Essai sur la Névralgie du Grand Sympathique_,
Paris, 1837.]
[Footnote 19: The disease frequently appeared on board of French
war-vessels, and was regarded by Lefèvre (_Recherches sur les Causes de
la Colique sèche_) as due to lead-poisoning. He asserts that lead is
more used in French ships than in those of other nations, and accounts
for its being epidemic in tropical countries because a warm climate
aids in developing the affection, and because there men drink more
freely of water. (See also Dutrouleau, _Arch. gén._, 1855, "Mal des
Européens dans les Pays Chauds.")]
[Footnote 20: Quoted by Oppolzer, _Wien. med. Woch._, Bd. xvi., 1867,
p. 724.]
The affection is not accompanied with any constant lesion. Pascal[21]
made post-mortem examinations in six cases and found the mucous
membrane of the duodenum a little reddened: the gall-bladder contained
thick bile, and in a few cases there was congestion of the sympathetic
ganglia. The attack is usually marked by certain prodromic symptoms.
The patient complains of malaise, loss of appetite, a load in the
epigastrium, embarras gastrique, dull pains in the colon, borborygmi,
and cramps or tingling in the limbs. For the first few days the bowels
generally move several times daily. The stools are difficult, painful,
and of a black or dark-green color, offensive odor, and accompanied
with the discharge of flatus. As the disease progresses the bowels
become constipated and the discharge of gas ceases. After a few days
the pain is more severe and radiates to the lumbar region, the
testicles, or the thighs. It is seated principally in the epigastrium,
in the line of the transverse colon, or it may involve the whole
abdomen. Movement aggravates the pain, while pressure often relieves
it. The tongue is large, trembling, and coated white or yellow; the
breath is fetid, the saliva viscid, and mouth sticky. Anorexia is
complete; there are hiccough, nausea, vomiting of undigested food and
mucous or bilious matters, and constipation with hard black stools. The
patient is restless and sleepless. The abdomen may be distended or
retracted, and micturition is often painful and the urine high-colored.
The pulse is generally slower than in health, but becomes accelerated
when the attack is over. The skin is pale, the conjunctiva often
stained with bile, and in the later stages oedema of the lids and
emaciation come on. The effect upon the nervous system may manifest
itself by amaurosis, deafness, delirium, mania, coma, epileptiform
convulsions, or paralysis. The paralysis affects the extensors of the
hand, arm, and leg, or it may become general and end in death.
[Footnote 21: "Recherches anatomico-pathologique sur la Colique dite de
Madrid," _Rec. de Mém. de Méd. mil._, Paris, 1826, xix. pp. 98-113.]
The duration of the disease is from eight to fifteen days, but in some
cases it becomes chronic. Relapses frequently occur. At times
intermittent or remittent symptoms develop, and occasionally the
affection is complicated with enteritis or peritonitis. The prognosis
depends very much upon the character of the epidemic, and the most
serious cases are those accompanied with either cerebral symptoms or
peritonitis.
The paralysis sometimes passes off in a few days, but oftener lasts
indefinitely. Emetics, purgatives, and anodynes are recommended in the
treatment of the disease, and frequently a change of climate is
necessary in order to recover fully from the affection.
DIAGNOSIS.--The diagnosis of enteralgia usually presents some
difficulty even when the symptoms are well marked. That the disease is
a true neuralgia is apparent from the periodical recurrence of the
pain, its sharp and darting character, from the sudden cessation
followed by complete relief, and from the absence of symptoms of
indigestion. Affections bearing a certain resemblance to enteralgia are
to be excluded.