Chapter XL: Front Matter (40)

Intussusception has been attributed to the weight of a mass of feces. Typhlitis and perityphlitis may come from retention in the cæcum. Pressure upon the viscera brings about derangements in their functions, many of which have already been described. From straining at stool a hernia, hæmoptysis, or cerebral hemorrhage may happen. Cases have been reported of death from rupture of an aneurism of the aorta while at stool, and J. F. Hartigan met with a case of spontaneous rupture of the aorta, where the vessel was apparently but little diseased, occurring in a man aged sixty during the act of defecation.[35]

[Footnote 35: Hartigan, _Tr. Med. Soc. District of Columbia_, vol. i. No. 3, 1874, p. 55. See also same number for a valuable paper on spontaneous rupture of aorta, by J. J. Woodward.]

{649} The effects upon the general system are those connected with malnutrition. The health may be profoundly altered and death occur from secondary diseases. Many general symptoms are due to the retention in the blood of excrementitious matters or to their reabsorption.[36]

[Footnote 36: Sterk, "Ueber den schudlichen einfluss der chronischen Stuhlverhatten auf den Gesamur organismus," _Wien. med. Presse_, xxii., 1881, p. 330 _et seq._]

DIAGNOSIS.--The diagnosis of constipation is not difficult except in hysterical women, who select this as one of their subjects of deception. Primary must be distinguished from secondary constipation, the last being a symptom of some general or local disease. The history of the case and the predominating symptoms will be guides to a decision, but constipation should be regarded as a symptom until it is proved to be otherwise. The tendency is to look upon it and to treat it as a distinct malady; important organic changes elsewhere may thus be overlooked. Simple habitual constipation may be mistaken for constipation due to lesions in the wall of the intestine or to closure from the external pressure of tumors.

Slowly-developed symptoms of obstruction may come from polypoid growths or benign tumors in the rectum, colon, cæcum, duodenum, and ileum. They are usually found in the rectum. The diagnosis can only be made when the growth is in the rectum or when the tumor is expelled from the bowel. Cancerous obstruction is accompanied by cachectic changes, by the presence of an abdominal or rectal tumor, the passage of blood and mucus, and violent rectal or abdominal pain. Primary cancer in the small intestine appears in the form of lymphoma; it readily ulcerates, and rather widens than narrows the channel of the bowel.[37]

[Footnote 37: Wilks and Moxon, _Path. Anat._, Philada., 1875, p. 417.]

Stricture of the bowel is most commonly found low down in the rectum or sigmoid flexure, within reach of the finger or exploring bougie. If high up, it can only be diagnosed by exclusion and by its slow progression from bad to worse. Syphilis or dysentery has nearly always preceded the development of stricture.

Tumors in the abdomen or pelvis compress the colon, and while they are small they may be overlooked; sooner or later they grow so as to be recognized.

The presence of gall-stones as obstructions may not be detected until they are passed. The previous occurrence of attacks of hepatic colic, followed by jaundice, gives rise to the suspicion that gall-stones are in the intestine if they have been carefully looked for in the stool but never found.[38] Enteroliths give no indication by which they could be known to be in the bowel.

[Footnote 38: In a case seen by the author three separate attacks of typhlitis occurred in a young woman suffering from chronic constipation. After the last attack she passed from the bowel several dark, irregularly-shaped concretions. The largest of these was a gall-stone covered with fecal matter. Since this time--two years ago--there has been no recurrence of inflammation and the constipation is much better.]

All forms of constipation from organic modification of the walls grow worse and have no remissions; some rapidly progress toward a fatal termination. Simple constipation is subject to improvement and relapses due to the character of the food, climate, exercise, etc. The etiology is an important guide.

Stercoral tumors may be known by their position and character as {650} ascertained by physical examinations and by their history. They are found in the iliac, lumbar, or hypochondric regions, and sometimes in other parts of the abdomen. The most common seat is in the sigmoid flexure and descending colon. They are nodulated, movable, painless, can be made to change shape or are indented by pressure, and have a doughy feel. Exploration of the rectum, by detecting impaction, will make the diagnosis clear when the obstruction is low down. The distension of the abdomen above the point of obstruction is limited at first to the region of the colon; but if the colon is much dilated with gas or is displaced, the enlargement becomes more central and more general. On percussion the sound is of a dull tympanitic quality, and never absolutely dull even in cases of great fecal accumulation.[39]

[Footnote 39: Case referred to by Guttmann (_Physical Diagnosis_, Sydenham ed., p. 360), in which the sound was dull tympanitic over two large fecal tumors which weighed when removed at the post-mortem six kilogrammes (sixteen pounds).]

Fecal tumors[40] are preceded by habitual constipation, and are most common in elderly people; they are changed in position and size or made to disappear by cathartics or rectal injections. Persistent treatment will bring away scybalæ which by their color and consistence show that they have long been in the canal. But the free movement of the bowels and the non-disappearance of the tumors are no proof that they are not fecal.

[Footnote 40: _Tumeurs stercorales_, Paris, Thèsis No. 240, 1878.]

Fecal accumulations have been mistaken for ovarian tumors,[41] cancerous tumors of the mesentery, uterine fibroids, and retro-uterine hæmatocele. Fecal tumors in the transverse colon have been taken for enlargement of the liver and spleen. In one instance obstruction of the bowel from fecal impaction was supposed to be a strangulated gut in a patient suffering from hernia: an operation was performed, the patient dying in sixteen hours afterward.[42] Ovarian tumors in their early stages are sometimes thought to be fecal.[43]

[Footnote 41: Jas. Y. Simpson, _Med. Times and Gazette_, London, 1859, vol. ii. p. 549.]

[Footnote 42: Thomas Bryant, _Med. Times and Gazette_, London, vol. i., 1872, p. 303.]

[Footnote 43: J. B. Brown, _Lancet_, London, 1850, vol. ii. p. 48.]

Fecal impaction in the rectum, with ulceration and bloody and mucous stools, may for a time be called cancerous ulceration. Sacculated scybalæ cannot be distinguished from submucous tumors even by the hand pressing on them in the rectum.[44]

[Footnote 44: H. R. Storer, _Gynæcological Journ._, 1869, vol. i. p. 80.]

The history of each individual case, a full knowledge of etiological factors, and a careful physical examination will in most instances lead to a proper diagnosis.

PROGNOSIS.--The result of treatment depends upon the age. Although in infancy constipation is very common, cure is the usual result where a mixed diet begins to be taken in childhood. At from one to fourteen years of age regular movements can usually be secured, unless there is a radical defect in the organization of the child. In young girls at puberty and after, if constipation once is established it is apt to become inveterate, associated as it is with imperfect development and with uterine displacements. In middle life in men the result depends upon the cause and upon attention to the physician's counsel. If intestinal catarrh or atony is the cause, a persistent subordination of the life of the individual to the object in view will generally end in cure. In women who have borne {651} children the hope of relief depends upon the duration of the malady before treatment. It is a dispiriting task to attack a constipation of many years' standing in women with relaxed abdomens, uterine prolapsus or retroversion, and general debility. In old age the causes are generally such as cannot be removed. The bowels can be moved when the occasions demand, but there is very little expectation of establishing a spontaneous habit of regular fecal movements.

At every age and from whatever cause perseverance and hope on the part of the patient and doctor are the chief elements of success. In neglected cases the worst results may happen: dilatation of the colon, ulceration, fecal impaction and obstruction, perforation; or in milder cases chronic indigestion, hypochondria, etc.

TREATMENT.--The physician can render great service by giving to parents advice which will prevent constipation in children. He should insist upon the importance of habits of regularity in defecation. At the period of puberty in young girls this is of even greater moment, and no opportunity should be lost for pointing out the danger of neglect. As a prophylactic measure in adults counsel should be given suited to the occupation. To persons leading sedentary lives the necessity of exercise ought to be made clear. In the trades little can be done, but in the case of literary men and those who read or write for many hours prevention is easier than cure. Daily exercise, walking or riding, frequent bathing with active sponging and friction of the surface, especially over the abdomen, will be of much service. Avoiding constrained positions where pressure is brought to bear upon the abdomen, as in bending forward to write, is quite an important item. Among ignorant people advice of this kind is rarely attended to, but even here the doctrine of regularity should never cease to be preached. Active business-men, especially young men, need emphatic teaching. They cannot plead ignorance for the habitual and persistent neglect of the simplest rules of health of which they are in this country so often guilty. The symptoms of indigestion which are precursors of constipation should receive due attention, and a mode of life and dietary suited to a complete digestion of the food will favor the timely and proper expulsion of waste matter.

Acute constipation in a previously healthy person, lasting for one to three days, does better without interference. No harm attends temporary inaction of the bowel, and if a spontaneous stool takes place at the end of this time it is a sign of a healthful and vigorous condition. After this the normal regularity is restored. The habitual clearing out of the bowel by a purgative pill or dose of mineral water whenever such a state of matters occurs creates the necessity for the interference. The man who never lets himself go over a day without an action is miserable if he misses his purgative and its effects.

In the onset of acute diseases the custom of giving a preliminary purgative is generally unnecessary, often injurious. It disturbs the rest which such cases need; it produces exhaustion in some diseases, as pneumonia, pleurisy, and rheumatism; it irritates the mucous membrane when irritation involves danger, as in intestinal catarrh and typhoid fever.

When it is desirable to empty the bowel in acute constipation a warm-water enema for adults and children is the best means. When a laxative is necessary in case of a failure of the enema, one mild in its operation {652} should be chosen--a compound rhubarb pill, one to five grains of calomel, a teaspoonful of Rochelle salts, or half a bottle to a bottle of the solution of the citrate of magnesia or the tartro-citrate of sodium. For children calomel, in doses of one-third of a grain to one grain, is one of the most certain and least objectionable. One grain of powdered rhubarb can be added to this for a more active effect.

Under such circumstances as a blocking up of the bowel with a mass of partially digested or undigested food, fruit-stones, skins, or other foreign bodies, where the symptoms are violent pain, tympanites, and vomiting, the best method is to give large enemata of warm water through a long rectal tube passed as high up as possible, and to administer calomel in doses of one to three grains, repeated every two to three hours until the bowels are moved. Cold can be applied to the abdomen to diminish tympanites and prevent inflammation. Should the constipation not yield and the pain, vomiting, and tympanites augment, the case will then be considered one of intestinal obstruction, and be treated as such.

When called upon to treat chronic constipation, the physician should remember that it is not the symptom, but its causes, to which he should direct attention. Constipation is so often a symptom, a complication, of other diseased states that its management is a matter of secondary importance. Moreover, its causes are so peculiar to the individual and depend upon so many variable habits of life that each case asks for special study. The cure is only to be found by learning the particular cause--the habit of neglect, hurried eating, the use of aperients, uterine displacement, or any of the many causes enumerated.

The digestion and all that concerns it is of primary importance, and to it attention should be at once directed. The stomach and intestinal digestion should be examined separately, and the relative power to digest different articles of food determined. A diet, then, should be selected, not with a view to correcting the constipation, but as to its suitability to the digestive capacity of the patient. No system of diet can be fixed upon as suited to every case: the aim is to secure normal digestion and absorption and normal peristalsis. Many trials may have to be made before a proper dietary can be chosen. When there is indigestion of fats and malnutrition, with pale offensive stools containing much mucus, an exclusive nitrogenous and easily digestible diet--such as is advised in the article on INTESTINAL INDIGESTION--should be prescribed. In constipation connected with membranous enteritis a similar system of diet is proper. The drugs given should be those which aid intestinal digestion, and reference must be made again to this subject, already treated of. Many cases of constipation can only be cured by this treatment; the routine treatment by purgatives and a diet of vegetables and fruits would aggravate and not relieve. A course of exclusive milk or skim-milk diet, if persevered in for some weeks, will cure cases of constipation of this kind without the use of laxatives. Of course a purgative must sometimes be given if enemata fail, but the least irritating one should be selected.

The mineral waters best suited to constipation depending upon intestinal catarrh are in this country those of the Rockbridge Alum Springs and Capon Springs (Va.), the California Seltzer Springs, and the milder {653} waters of Saratoga. The most suitable from Europe are the waters of Apollinaris, Vichy, Buda, Vals, Ems, Salzbrunn, Selters, Mt. Doré, and Kissengen. The warm baths of Virginia (Warm Springs, Hot Springs) are useful in increasing the activity of the skin and in giving relief to the catarrhal state. A month spent at the Warm Springs, with a daily bath the natural heat of which is 98°, will work a complete transformation in the abdominal circulation. This should be conjoined, of course, with a properly-regulated diet and exercise. Another month spent at the Rockbridge Alum Springs will complete the restoration of the bowel to a normal state. It is much to be regretted that the really valuable mineral springs of Virginia lack so many of the comforts which the invalid requires. In cases where it is more convenient a stay at the Arkansas Hot Springs is to be suggested, and for obstinate cases of intestinal catarrh with sluggish circulation, obesity, and gouty tendencies these springs are to be preferred. A season at some of the mineral baths of Europe, as Aix-la-Chapelle, followed by the strict regimen of the grape cure (as at Bingen, Durkheim, Vevay, Montreux, or Meran), is a rational mode of treatment which offers an almost certain prospect of cure.

If the case is one of atony of the colon due to impaction of the rectum and dilatation of the rectum and colon, without gastric or intestinal indigestion, a quite different regimen is required. The constitution and mode of life are the guides to the general plan to be followed. Sedentary pursuits are to be given up as far as possible. Long vacations and travel must be insisted on, with active exercise by walking and riding; also cold bathing or sponging, with brisk friction of the whole body. Sea-bathing is useful both as an exercise and for the effect upon the sluggish peripheral circulation, but the slothful life at the seashore, with over-indulgence in eating and drinking, is a source of more harm than good. Warm baths, and cold douches to the abdomen, compresses of cold water or of alcohol, the cold douche to the spine while in the hot bath, are all beneficial. Massage for women, children, and feeble persons takes the place of exercise. The kneading of the muscles over the abdomen can be combined advantageously with an effort to accelerate the passage of the contents of the colon by manipulation in the direction of movement.

The interrupted electrical current, used for the purpose of developing the feeble abdominal muscles, is a source of much advantage.[45] But to be of service it should be persevered in for months, the patient himself making the application under the direction of the physician. In addition, the introduction of one insulated electrode into the rectum, while the other is in contact with the abdominal muscles or along the line of the large intestine, has been advised. The Swedish movement cure may be a useful aid in some cases. The movements exercise the muscles of expulsion. These are deep inspiration, flexion and extension of thighs or trunk, twisting the trunk, pressure on the abdomen and colon, stroking in the direction of fecal movement.

[Footnote 45: S. T. Stern, "Die faradische Behandlung der Obstipation und der nervosen Enteropathie," _Centralblatt für Newenheil_, 5 Jahrg., Mai, 1882, p. 201; also, I. Althaus, "Treatment of Obstinate Constipation by Faradization of the Bowel," _Lancet_, London, 1867, ii. 606.]

In the relaxed condition of the abdomen in women who have borne {654} children or in old persons the wearing of an abdominal support sometimes gives help and comfort.

The best diet for cases of atony of the colon and rectum is one which is easily digested and has a moderate amount of waste, as a full colon will stimulate muscular action. Various articles are suggested with a view to excite peristalsis by irritation of the mucous surface, but as such substances are in themselves insoluble and innutritious, it is unwise to resort to them. The following list includes the foods suitable to such cases: Fresh vegetables, as spinach, raw or stewed tomatoes, lettuce, kale, salsify, peas, asparagus, kohlrabi, and other summer vegetables; in winter canned vegetables, if well prepared, take their place. Among fruits, fresh fruit in general, especially grapes, peaches, and oranges; dried fruit, as figs, raisins in small quantity, stewed prunes, and baked or stewed apples, can be tried.

Too much vegetable matter is harmful, as the bowel is filled with an excess of waste, much of which is undigested food; the quantity must be regulated by the appearance of the stools and by the success of the regimen. If the blockade continues obstinately, the vegetable diet should be reduced. The microscope in many cases can alone decide the amount of undigested vegetable matter. Meats are all advisable in moderation. The least digestible, as ham and veal, are to be avoided. Graham-flour bread, brown bread, or bran bread are better than bread made of the best bolted flour. The first is more digestible, and bran bread[46] is thought to increase peristalsis, but this is a doubtful effect. Oatmeal well boiled, fine hominy, corn meal, or cracked wheat with milk are pleasant and digestible. A cup of café au lait at breakfast or before breakfast is the best morning drink;[47] it has a laxative influence. Tea is thought to have the opposite effect. Milk at breakfast answers well for those who take it with relish. An orange on rising in the morning is a pleasant remedy.

[Footnote 46: "The Efficacy of Bran Bread in relieving Despondency ... dependent on an Irregular and Constipated State of the Bowels," _Journ. Ment. Sci._, London, 1858-59, v. 408-411.]

[Footnote 47: "Treatment by Café au Lait," _Gaz. des Médecins prat._, 1840, No. 4, p. 13.]

Certain drugs are called for to aid these measures in giving tone directly or indirectly to the weakened bowel muscles. Strychnia stands first, but it woefully disappoints one who trusts much in the theoretical arguments for its use. In fact, it may be said of all drugs given for constipation that they stand in a very subordinate rank to the measures already discussed. They should be thought of last, not first, and but little confidence should be put in the vaunted value of new drugs. Strychnia can be combined in anæmia and debility with the dried sulphate or carbonate of iron, and with quinia or arsenic,[48] or in feeble digestion with dilute hydrochloric acid and pepsin. Belladonna was advised by Trousseau as a stimulant to unstriped muscular fibre, and it can well be given with strychnia; ipecacuanha and atropia are approved of in conjunction.[49] A pill of ergot, belladonna, and strychnia would answer the indication of a feeble peristalsis. DaCosta has suggested giving one drop {655} of the fluid extract of belladonna with compound tincture of gentian or cinchona three times daily after meals. The sulphate or valerianate of zinc, oxide of zinc, extract of valerian or gentian, capsicum, or black pepper can be tried in pill form with belladonna and strychnia.

[Footnote 48: Bartholow thinks arsenic overcomes constipation when due to deficient secretion and dryness of the feces (_Mat. Med._, New York, 1879, p. 129).]

[Footnote 49: Legros and Onimus, _Journal de l'Anat. et de la Phys._, t. vi. pp. 37 et 163. Ringer says one grain of ipecacuanha taken while fasting each morning will relieve constipation from torpor (_Therapeutics_, New York, 1882, p. 438).]

These remedies are slow-acting, and in the mean while the bowels must be moved artificially, methodically, and taught to act at stated hours. For this purpose a small enema of cool or cold water at the same hour every day after breakfast does well. It is irrational to distend the bowel, already weakened by distension, with large enemata of warm water. Recourse should not be had to this until all hopes of effecting a cure are gone, or only as an occasional remedy in impacted accumulations where the mass must be softened before it can be removed. If the enema does not in time empty the colon sufficiently, laxatives will have to be taken with some regularity until the habit is created. A tumblerful of water with or without a teaspoonful of salt, or a tumblerful of any alkaline water charged with carbonic acid, taken on rising in the morning, may prove effective. A tablespoonful of sweet oil at night acts well as a lubricator and softens the feces. If these more simple means fail, it becomes unfortunately necessary to give a purgative drug: any one of this class can be combined with strychnia, belladonna, vegetable tonics, and iron. Those to be preferred are aloes, colocynth,[50] and podophyllin. The compound podophyllin pill or a pill of one-sixth of a grain of belladonna and podophyllin at night or three times daily, the pill of aloes and myrrh, or the Lady Webster pill, are well-approved forms of administration. A compound rhubarb pill acts well if taken after dinner.

[Footnote 50: A few drops of the Prussian tincture of colocynth several times daily is advised by Ringer (_Therapeutics_, New York, 1882, p. 642).]

If one desires to select a purgative which will probably increase the outflow of bile, selection can be made from the following drugs: podophyllin, aloes, rhubarb, colchicum, euonymin, colocynth, calomel, jalap, sodium sulphate, potassium sulphate, cream of tartar; and among the rarer alkaloids iridin, sanguinarin, physostigma, and juglandin. These, according to Rutherford, Vignal, and Dodds, increase the secretion of bile in fasting animals. Ox-gall and pig-gall are laxatives only; they have no effect on the liver, but can be added to other purgatives in pill forms.

Salines largely diluted may be given to strong adults: Epsom or Rochelle salts quite early in the morning, a solution of sulphate of magnesia with dilute sulphuric acid, to which dried sulphate of iron may be added, are quite popular; and of the bitter waters, Hunyadi Jânos, Friedrichshall, or Pullna water serves the purpose. One grain of sulphate of quinia added to a saline will increase its effect. The milder laxative waters are to be preferred to the bitter waters. The Saratoga waters, Congress, Geyser, Hathorn, answer the purpose taken early in the morning, or among the European springs those of Kissengen, Plombières, Marienbad, Homburg, Seltzer, or Leamington in England, are not too active in their effects. In atonic constipation, the form now under consideration, the laxative chalybeate waters are indicated where there is anæmia or debility. These are represented by the Columbian, Pavilion, Eureka, and Excelsior Rock among the Saratoga waters, and by the Bedford Springs water.

{656} It is well to administer a number of drugs in rotation in habitual constipation, as the susceptibility to a particular drug is lost after continued use. Increase of the dose is the usual method to offset this result, but it is irrational to meet exhaustion by over-stimulation. Rest of the part stimulated by using a remedy which brings about the result in a different way is the wiser course. The dose should be gradually reduced, tempting the bowel to act more and more without aid. Among the laxatives which can be borne in mind in alternating treatment the following list includes some which can be used with advantage: the fluid extracts of rhamnus (buckthorn) and cascara sagrada; alum, which is called for in certain forms of atony; sulphur in the form of confection or sulphur with guaiacum[51] (half a drachm of each in powder at night); the wine of colchicum (five drops or more three times daily), advantageously used in gouty or rheumatic persons; the infusion or tincture of euonymus; the tincture of benzoin; senna in fluid extract and in the compound powder of liquorice.

[Footnote 51: Fuller, _Lancet_, London, April 23, 1864, p. 459.]

Infants and children should be cured of constipation without purgatives if possible. Attention to the diet of the infant, and close inspection of the stools to see the effect of the food given, will guide to a proper system of feeding. Breast-milk is the best remedy; next, a food which most nearly resembles mother's milk--cow's milk properly diluted with barley-water, oatmeal-water, or rice-water--stands first. Condensed milk, given in barley- or oatmeal-water, is a second and excellent substitute in cities. Antacids prevent a too rapid coagulation of the casein and the formation of curdy lumps. Lime-water with milk or bicarbonate of potassium or of sodium may be administered with the food or before it. The quantity of food must be lessened until the child can digest all it takes.

The infant should be taught to empty the bowel at the same hour daily 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.

In lumbo-abdominal neuralgia the pain is unilateral and extends around {664} to the back. Tender spots can usually be detected by pressure on the umbilical or hypogastric regions or on the spinous processes of the vertebræ. In dermalgia the soreness is superficial, and light pressure gives more pain than deep compression, while nervous and hysterical symptoms are constantly associated with this form. Gastralgia is more frequent than enteralgia, and the pain is located about the ensiform cartilage. In myalgia of the abdominal parietes pressure causes pain, as do also movements of the body, coughing, sneezing, etc. Rheumatic pains would likely be felt in other muscles. In ileus the pain is more continuous, the tenderness localized; there is constipation of a most obstinate character, and vomiting of stercoraceous matter. The patient has an anxious expression and a rapid, feeble pulse. In renal calculus the pain is situated in the course of the ureter and shoots down to the pubes and thighs. There is frequent desire to urinate, accompanied by a scanty discharge of urine, and a copious flow of urine is followed by cessation of pain. The maximum of pain in hepatic colic is situated in the right hypochondrium, and is often reflected into the shoulder of the same side. Icterus may also be expected. Colic arising from lead-poisoning is usually associated with sufficiently characteristic symptoms to render the diagnosis easy. When syphilitic the pain is apt to be most severe at night.

In catarrh of the bowel the skin is hot and dry, the pulse accelerated, and other indications of a symptomatic fever are presented. The pain is more constant, more localized, and pressure causes it to be increased. Tenderness on pressure is not invariably met with, but the rule holds good that when deep pressure increases the pain inflammation rather than enteralgia is indicated.

If colic is due to indigestible food, a sensation of weight will be complained of at the epigastrium, griping pains occur at short intervals, with flatulence, vomiting, and later diarrhoea. If the attack be wind colic, the abdomen is enlarged by tympanitic distension; borborygmi and belching occur. If it is the result of accumulation of feces, there would be a previous history of constipation, and the lump of feculent matter can be located by palpation and percussion.

PROGNOSIS.--The prognosis of idiopathic enteralgia is favorable, the disease generally terminating after a variable period. Attacks are very apt to recur, and each one will, in all probability, prove more severe than the preceding. In symptomatic enteralgia the prognosis will depend upon the nature of the fundamental disease.

Colic terminates favorably in nearly every case. Death has rarely occurred from complications, as convulsions, and rupture of the bowel has been observed from great distension.

TREATMENT.--If attacks of enteralgia are associated with hysterical symptoms, it would be proper to employ antispasmodic sedatives. The compound spirit of ether is very useful in these cases, especially if they are accompanied with flatulence. Rubbing the spine with stimulating or anodyne liniments frequently promises well. The hypodermic dose of morphia gives relief more quickly than can be got in any other way, but in pure enteralgia with frequently recurring paroxysms care must be taken not to create the demand for the remedy by giving it often. The radical cure of the disease is a more important matter than the treatment of the acute attacks.