symptoms those of internal strangulation of the bowel, often followed
by collapse, which may destroy life in a few hours. These cases are
{849} chiefly jejunal and iliac invaginations, and the higher up in the
small intestine the seat of obstruction the more violent and urgent the
symptoms. Constriction, being great, is followed by engorgement and
inflammation of the invaginated bowel, and if the patient lives long
enough gangrene ensues, by which the obstructing mass is separated and
discharged en masse or in fragments through the anus. Not unfrequently
life is saved in this way. That gangrene has taken place and separation
of the invaginated segments is in progress are often known by the very
fetid character of the evacuations and by their admixture with blood
and shreds of necrosed bowel. When the sequestrum has been detached
entire, it is often passed with difficulty. Frequently it lodges at
some point in the bowel, producing temporary obstruction and giving
rise to tenesmus and pain as it passes along the large intestine. There
is no doubt that the continuity of the intestine above and below the
neck of the invagination has been established, and complete cures
effected in the way already mentioned. Usually, however, the patient
dies from collapse, peritonitis, or perforation of the bowel before the
obstructing mass can be removed by gangrene. Children almost invariably
die before this can take place, and adults live from the seventh to the
fourteenth day, according to the greater or less violence and acuteness
of the symptoms. When the slough has been discharged and the continuity
of intestine established, recovery is still uncertain, and death very
often happens for reasons referred to in speaking of the separation of
the sequestrum.
Separation of the invaginated portion and its expulsion, according to
Leichtenstern, in the majority of cases takes place from the eleventh
to the twenty-first day, but in chronic cases it is often delayed for
months. According to Brinton, separation of the sequestrum occurs
between the eighth and fifteenth in intussuscepted small intestine, and
between the fifteenth and twenty-second days in acute cases of
ileo-cæcal and colic invaginations.
In chronic cases of intussusception, which usually embrace the
ileo-cæcal and colic varieties, strangulation is not common and the
course of the disease is protracted. These cases often last for several
months, and the symptoms are not always well defined. At first the pain
is paroxysmal, with long intervals of ease. Vomiting succeeds, but is
not persistent; discharge of the contents of the bowel below the seat
of lesion takes place and afterward fecal matter from above this point,
because the permeability of the bowel is not usually lost in chronic
cases. Eventually the alvine discharges become bloody, mucoid, and
characteristic of intussusception; the severity of the symptoms may
gradually increase, the pain becoming greater, more constant, the
vomiting more incessant, the discharges from the bowels more frequent,
and in one, two, or three months the patient dies from asthenia.
Several authentic cases are related where the disease lasted one or two
years before terminating fatally. Very often some days before death the
pain and tenderness cease, and the operations become free from blood
and normal in character.
{850} Constipation.
Constipation is a prominent symptom in all of the conditions which give
rise to intestinal obstruction, and habitual constipation or loss of
the powers provided for the advance of the contents of the intestines
not unfrequently leads to permanent occlusion of the canal. It is
impossible to fix any definite rule as a standard of health for the
number and quantity of alvine evacuations. Some individuals have a
passage from the bowels once every day; others, in the enjoyment of as
good general health, suffer from the ordinary inconveniences of
constipation if they have less than two or three daily fecal
discharges; others, again, apparently equally as well, have a movement
from their bowels once in two or three days or once a week, or even
once in two weeks. Habershon[7] records the case of a "woman sixty
years old who from youth upward had had a passage from the bowels only
every six or eight days, and whose health had been perfect." A lady
under my own observation, for twenty years never had an alvine
discharge oftener than once in two weeks, and three times in her life
had passed two months without a movement of her bowels. This lady was
the mother of several children, and, although not in perfect health,
was able to attend to her ordinary household duties. Such cases are not
very uncommon, and occur, as far as I have been able to ascertain, more
frequently in women than in men.
[Footnote 7: _On Diseases of the Abdomen_, quoted by Leichtenstern in
_Ziemssen's Cyc. P. of Med._, vol. vii. p. 588.]
The number of fecal evacuations and the quantity discharged have been
shown by Bischoff and Voit to depend, to some extent, upon the
character of the food ingested, vegetable diet producing abundant, and
animal diet scanty, stools. Doubtless, the quality of the food partly
explains the quantity of the alvine evacuation, although, to some
extent, this must depend upon the time that the feces remain in the
colon, a long residence there taking away a greater part of the watery
constituents and making the fecal mass thicker and harder; but the
variations in the number of stools in persons living on the same diet
can only be explained by the variations in the activity of the
peristaltic action in different individuals, or in the same individual
at different periods and under different surroundings.
The causes of habitual constipation are of the most varied and
diversified character, and it is not always possible in an individual
case to point out the original or primary one. Not unfrequently several
causes are in operation at the same time to produce sluggishness of the
intestinal canal and constipation. Very often it begins with change of
scene and habits, by which the daily visit to the water-closet is
interfered with, or after confinement to bed with some temporary
indisposition. It is more likely to occur in men and women whose habits
are sedentary and who are constitutionally lazy and indolent. The feces
are allowed to remain in the rectum and colon, and every hour after the
ordinary time for going to stool diminishes the watery parts of the
fecal mass and makes it harder and more consistent. Many cases of
chronic constipation, begun in this way, have ended in dilatation and
thickening of the intestine, ulceration of the mucous membrane, and,
eventually, perforation of the coats and escape of the contents of the
gut into the peritoneal cavity. Rapid {851} excretion of water by the
kidneys, lungs, and skin produces constipation by withdrawing a large
proportion of the water from the fecal mass, rendering it unnaturally
dry and of diminished bulk. In diabetes, constipation arises from this
cause unless the patient makes up the loss by drinking an unusually
large quantity of water. Constipation in nursing-women is explained by
the loss of water in the secretion of milk. The profuse sweating which
attends malarial fever, phthisis, and other diseases readily accounts
for the constipation which often accompanies these disorders.
Certain articles of food not necessary to mention here produce
constipation. They fail to excite peristaltic action; or articles of
diet which at first act as a stimulus to the bowels, and even provoke
temporary diarrhoea, lose their power if kept up too long--just as
certain purgative medicines lose their force if continued for too long
a period. Gradually they cease to increase the peristaltic action, and
rather add than otherwise to the inactivity of the intestines. Eating
the same kind of food day after day is very apt, sooner or later, to
result in diminished sensibility of the intestinal canal, a reduction
of the peristaltic force, and deficiency in the secretion of the
digestive juices, which in itself is a common cause of constipation.
Frequent change of diet is generally needed to supply the stimulus
necessary for that intestinal motion which relieves the bowels.
Bile is looked upon as one of the most powerful agents in stimulating
peristaltic action, and when, from any cause, mechanical or otherwise,
it is not poured into the bowel, constipation ensues. Unnatural
flexures, congenital or acquired, of the large intestine are not
unfrequently the source of chronic constipation. These flexures, normal
or factitious, favor accumulation of feces, especially in subjects who
have diminished sensibility of the bowel and a paretic state of the
muscular coat. Certain injuries and diseases of the brain and spinal
cord reduce, and sometimes altogether prevent, intestinal activity.
Hysteria, if it exist for any length of time, is generally attended by
sluggishness of the bowels, and great mental depression (melancholia)
is sometimes preceded and sometimes followed by habitual constipation.
In treating such a case it is important to make the distinction.
Temporary paralysis of the muscular coat of the bowel, followed by
symptoms of intestinal constriction, with insuperable constipation,
sometimes attends violent contusion of the abdomen. In some cases
prolonged functional weakness of the muscular coat follows the injury.
Many chronic diseases leave the bowel in a sluggish condition by the
pathological changes produced in the intestine. The function of the
muscular coat is frequently injured by the infiltration which
accompanies peritonitis. The fibres are separated by the serous
effusion which attends this inflammation; they become overstretched,
and, losing their contractility, end in paralysis and obstinate
constipation. Occlusion of the canal from this cause may last for days,
and be accompanied with tympanitis, stercoraceous vomiting, and all the
signs of internal strangulation, ending in death. Post-mortem
examinations in such cases show no stricture or unnatural diminution in
the size of the canal, but that the fatal occlusion was due to
paralysis of the muscular coat of the bowel and arrest of its power.
The normal advance of the contents of the bowel is interfered with by
any cause which lessens the contractility of the muscular coat. Chronic
{852} diseases which debilitate the general muscular system affect at
the same time the contractile power of the muscular coat of the canal,
and the debility and degeneration of old age are felt here, and
sometimes occasion the constipation which often accompanies this period
of life. Leichtenstern[8] says that chronic intestinal catarrh is a
common factor of constipation--that when this catarrh is of long
standing it produces relaxation of the muscular coat and diminishes the
elasticity of the intestinal walls. He believes that this pathological
condition exists in a large proportion of the cases of habitual
constipation attended with mental depression, that the hypochondriasis
makes its appearance after the constipation has become chronic, and
that it is a secondary symptom. This affection is located chiefly in
the small intestine, and does not usually involve the colon.
[Footnote 8: _Op. cit._]
Probably the most common form of chronic constipation is that which
accompanies loss of sensibility and muscular inactivity of the colon
and rectum. The large bowel becomes sometimes so distended by the
accumulated fecal masses that it has been found after death to measure
ten or fifteen inches in circumference and to contain an astonishing
quantity of feces. Any part of the canal, except the last two inches of
the rectum, which is kept empty by the contraction of the sphincters,
may be occupied by the mass, but the accumulation is greatest in the
rectum, cæcum, and sigmoid flexure. At the last-named location the
distension is so great that the mass can be readily felt through the
abdominal walls. The tumor may be as large as a foetal head, and may be
mistaken for a simple or malignant tumor of the omentum, stomach, or
other organ, or for pregnancy or ovarian growth. The dilatation may be
so enormous as to push the small intestines into the back part of the
abdominal cavity and to interfere with the function of any organ upon
which it encroaches. It may press upon the concave surface of the
liver, and, arresting the flow of bile, produce jaundice or
mechanically interfere with some portion of the track of the urinary
organs and cripple their functions. When situated in a portion of the
canal not tightly attached to the abdominal walls it is slightly
movable, more or less hard and consistent, according to its duration,
for it remains often for months unchanged, sometimes giving to the
fingers the impression of a rather soft, easily-indented swelling with
a uniform smooth surface--more often feeling like a hard, irregular,
elongated, and corrugated mass of fecal balls. Contraction here and
there of bundles of the circular muscular fibres of the gut produces
the irregular, corrugated impression imparted to the fingers. Their
shape and position may sometimes be changed by pressure through the
abdominal wall. If the accumulation occurs in the rectum, the
introduction of a tube or bougie is prevented by the impacted mass,
which can be gotten away only by the fingers or by some instrument. The
colon and rectum may be dilated to their utmost capacity with an
enormous amount of feces, enough to fill a common-sized pail, and both
the patient and medical attendant be deceived as to the sufferer's
condition by the fact that he has his daily number of stools. The
semi-fluid contents of the small intestines find their way through this
mass by some irregular and uncertain track, undermining and breaking
down sometimes a lump of the old fecal accumulation, which, if small in
size or broken up, may pass on and {853} escape by the anus, but if
large and hard may drop into the irregular and uncertain passage and
permanently close it; then sudden and complete intestinal occlusion
takes place, with all of its fearful consequences. If this, however,
should not occur, and the accumulation is not recognized and removed,
the enormous dilatation may go on until complete paralysis of the
muscular coat is produced, and entire stoppage of the current of feces,
with permanent occlusion of the bowel; or before this takes place
ulceration may set in, partly because of the great pressure of the
fecal mass upon the mucous membrane, and partly from the irritating
character of the contents of the bowel. Ulceration begins, most likely,
at some point where resistance is greatest, and perforation of the
bowel may ensue.
SYMPTOMS.--If the accumulation occupies only a portion of the colon, as
the cæcum or sigmoid flexure, the distended part may become displaced
and twisted on its long axis. This condition scarcely ever happens in
the large intestines except at the parts mentioned. Torsion of the
cæcum rarely takes place except in persons of from forty-five to sixty
years of age, while twisting of the sigmoid flexure may happen at any
period of life. When distended and very heavy from the weight of feces,
with probably some congenital defect about its mesenteric attachment,
the sigmoid flexure may become twisted and drop into the pelvis,
producing at once symptoms of internal strangulation.
Individuals accustomed to having one or more alvine evacuations a day
are made uncomfortable by two or three days of constipation. A feeling
of distension about the abdomen, with flatulence and heat, follows this
condition, and soon afterward headache, loss of appetite, and symptoms
of indigestion supervene. If this state of the bowels continues
unrelieved, pressure upon the hemorrhoidal veins takes place and
interference with venous return, producing congestion in the lower end
of the rectum. This is attended by straining, diarrhoea, evolution of
gaseous matter, colicky pains, and possibly sympathetic disturbance of
the genito-urinary organs. When at last the hardened and enlarged mass
is discharged, it produces some pain and burning about the anus, with
possibly rupture of the mucous membrane in that region. Fissure of the
anus may thus originate. In the case of a lad aged about nine years
under my care fissure of the anus began in this way, and after its
formation the pain of defecation was so intense that he resisted for
ten days every attempt of his bowels to move. After this time he passed
every day or two one or more hardened fecal balls, but always with such
atrocious pain that he looked forward to the next attempt with terror.
This case ended in fecal impaction, which nearly proved fatal.
Not unfrequently persons who habitually go two or three days without
having a passage from the bowels are not apparently inconvenienced, and
after a time any of the discomforts ordinarily felt from constipation
are not noticed, if indeed any exist.
Generally, however, chronic constipation leads to a host of troubles of
the most varied character. There is not an organ in the body that is
not more or less influenced by it. The generation of gas in the
intestines produces a sense of fulness of the abdomen and elevation of
the diaphragm which interferes with the action of the lungs and heart.
The sufferer is oppressed, sighs, and has difficult respiration and
attacks of {854} palpitation of the heart. The influence of the
abdominal pressure is conducted by the sympathetic nerves to the brain,
and the patient frequently has vertigo, headache, ringing in the ears,
faintness, etc., and in consequence of the pressure upon other nerves
or of hyperæmia of the spinal cord and its membranes he has dull aching
pains in his back, groins, genitals, or extremities. I have seen in
several instances pain in the legs, coming on after the patient has
retired and lasting until morning, violent enough to prevent sleep, at
once permanently relieved by an active cathartic after antiperiodics,
alteratives, and anodynes had failed to do any good.
A patient suffering from habitual constipation usually obtains
temporary relief by the bowels acting either spontaneously or after a
dose of medicine; but, the causes of constipation continuing, the
physical discomforts and suffering continue, varied in every
conceivable way. His digestion being disturbed, appetite poor, and
assimilation imperfect, he gradually loses flesh and his complexion
becomes sallow and unhealthy. In addition to this, he soon grows
irritable and fretful, trifling affairs trouble him, he has fits of
great mental depression, and soon settles down into hypochondriasis,
his life becoming a burden to himself and a nuisance to his friends.
If the constipation ends in fecal accumulation, the worst symptoms of
mechanical obstruction may present themselves at any time, and death of
the individual follow. The practitioner should always keep this fact in
mind in treating every case of intestinal obstruction, and search for
fecal impaction by examining the rectum and the whole length of the
large intestine through the anterior abdominal wall. Very often
symptoms of impaction come on gradually in one who has been ailing for
some weeks or months, but sometimes the onset is as sudden as in a case
of acute occlusion of the intestines. The patient is seized with pain
like that of colic and an urgent desire to empty his bowels, but all
attempts to do this are futile, and the straining is followed by great
exhaustion; borborygmus, nausea, vomiting, and possibly hiccough, soon
come on, with tympanitic distension of the belly. If the impaction is
not overcome, death by collapse or from peritonitis follows.
Post-mortem examination shows enormous fecal accumulation, peritonitis
as a consequence of the obstruction, perforating ulcer in some part of
the large bowel, more often the sigmoid flexure, or, in some cases,
absolute rupture of the cæcum itself, and escape of its contents into
the peritoneal cavity.
Stricture of the Bowel.
In a report by George Pollock[9] of 127 cases of intestinal
obstruction, 77 belonged to the above class; and Brinton, in his
analysis of the whole group of cases collected by him, says stricture
constitutes about 73 per cent. In 124 cases of intestinal obstruction
reported by Mr. Bryant[10] from the post-mortem records of Guy's
Hospital, 47 were found to be stricture of the bowel. The above
statements show that stricture, or diminution of the calibre of the
bowel, is the most frequent cause of {855} intestinal obstruction, and
the subject is worthy of our earnest consideration.
[Footnote 9: _Medico-Chirurgical Review_, 1853.]
[Footnote 10: _Practice of Surgery_.]
While stricture of the bowel may be found in any portion of the
intestinal canal, it occurs most frequently in the sigmoid flexure and
rectum. Brinton found in 100 fatal cases of stricture 30 in the rectum
and 30 in the sigmoid flexure; only 8 cases in 100 were in the small
intestine. Brinton's statistics correspond very nearly with those of
other writers. The affection is more common in men than women, and the
average age at death is about forty-four years.
The most common cause of stricture is contraction following
cicatrization of ulcers of the mucous and submucous coats of the
intestine. The ulcer may involve the circumference of the bowel, and
the resulting cicatrix terminate in uniform constriction of its lumen,
or the ulceration may extend several inches along the side of the
intestine, ultimately causing contraction in the direction of its
longitudinal axis, marked stenosis, and kinking of the gut. When
ulceration, continuous or in patches, involves a large extent of bowel,
it may reduce the gut to a mass of indistinguishable cicatricial
tissue. Bristowe[11] says he has seen the whole cæcum thus contracted
"into a channel barely capable of admitting a goose's quill."
[Footnote 11: Reynolds's _System of Medicine_.]
Stricture of the intestine often follows dysentery or tubercular and
syphilitic ulceration of the bowel. Follicular or hemorrhoidal
ulceration is sometimes the beginning of a stenosis which ends in
stricture of the rectum. Stercoral ulcers of the colon are not
unfrequently the starting-point of cicatricial contraction of the
calibre of the bowel. Sometimes, but rarely, ulcers of typhoid fever
end in constriction of the intestinal tube. The diameter of the gut is
also contracted by the effects of caustic substances, by ulceration
following the lodgment of foreign bodies, and by effusion of lymph or
thickening attendant upon long-standing hernia. Very often after death
it is impossible to determine what particular kind of inflammation and
ulceration caused the stricture. Generally, the cause which provokes
the ulceration sets up chronic peritonitis, which materially aids in
producing the obstruction. Spasm of the circular muscular fibres
usually accompanies these lesions, and materially contributes in many
cases to fatal intestinal obstruction. Some authors assert that spasm
without organic change can produce acute obstruction: such an
occurrence, except possibly in the rectum, must be very rare, if indeed
it ever happens.
The most common cause of stricture is cancer. This disease may
originate in the bowel itself, or, beginning in some neighboring organ
or tissue, gradually spreads and involves the gut. It may extend around
the bowel or be infiltrated along the sides of the canal for several
inches, and may be scirrhous, medullary, or epithelial in character.
Eighty per cent. of the cases of cancer of the bowel are situated in
the rectum. Usually, but not invariably, cancerous deposits are found
in persons who have passed middle age.
An impediment to the passage of fecal matter is invariably produced in
constriction of the intestine from the above causes, and it frequently
continues until fatal occlusion occurs. The contents of the bowel
accumulate above the block, producing distension of the gut and
thickening of the muscular coats above the stricture, with contraction
and atrophy {856} of the portion of intestine below. Dilatation of the
bowel above the seat of lesion is sometimes great enough to cause
rupture and peritoneal extravasation, or distension and stretching of
the coats of the canal may be sufficient to interfere with its
circulation, and ulceration ensue.
Occasionally cases of stricture or well-marked circumscribed
contraction of the bowel are seen which give rise to no marked symptoms
of constriction during life. Such was the case in the instance related
by Bristowe and referred to above. These instances are, however,
exceptional in the large intestine.