It is not very rare, says Hurst, to find people in perfect health who defecate regularly two or three times a day, and others with more greedy colons who do not do so in two or three days, without apparently suffering ill effects. There have been many cases observed in which the bowels acted at still longer intervals. A patient told Goodheart that her bowels moved regularly which, upon inquiry, turned out to be every eight days. He also mentions a man patient who obtained a fort-nightly evacuation by taking a pill on alternate Saturday nights! Heberden reports a case with a monthly period, while another had twelve actions every day for thirty years, and afterwards seven in a day for seven years, in the meantime gaining in weight?.
Cumulative constipation is a variety recognized by Field in which there is an insufflcient defecation; A case of this kind, recorded by Nothnagel, resulted in death from peritonitis following perforation of the colon by a large number of enormous stone-hard fecal masses, although the man never failed to have a daily evacuation. A patient of Ewald, whose bowels opened daily without symptoms, developed an abdominal tumor the size of a child’s head low down in the abdomen. After medication with castor oil the tumor disappeared. Ewald also refers to a case reported by another observer, in which low-down abdominal pains and distention were relieved by the passage of an enormous and almost unbelievable quantity of fecal matter although the bowels had been “perfectly regular.” Fragmentary evacuation, described by Boas, is a variety of this type. The feces are hard and dry owing to prolonged retention, dark in color and with little odor. The type is observed in some cases of colitis (discharge of mucus by the surface membrane of the colon).
Hurst makes a striking generalization when he says delay in the passage through the intestines is due (a) to the motor (muscular) activity of the intestines being deficient; or, (b) the force required to carry the feces to the pelvic colon being excessive. Apart from organic obstruction the delay in either case is most frequently confined to the large intestine below the hepatic flexure (bend from ascending to transverse colon), this being the location where the intestinal contents begin to be more or less solid, so that additional force is required for their propulsion. Moreover, an increasing resistance is offered to the progress of the contents as they pass to-wards the pelvic colon, because the interior diameter of the cecum and ascending colon is much greater than that of the transverse colon. The latter diminishes in size as it approaches the splenic flexure (bend from transverse to descending colon), the diameter of the descending colon being smaller than that of any other part of the large intestine. Corresponding with the greater force required to carry the contents along the lower parts of the large intestine, the thickness of the muscular coat of the empty bowel is greater in the descending and pelvic colon than in the transverse colon, and greater in the latter than in the cecum and ascending colon. (Roith.) Under certain conditions, however, in spite of this compensatory mechanism, the muscular power of the lower colon is unable to perform its functions in an adequate manner.
Internal secretions of some of the ductless glands when deficient, influence the motor activity of the intestines. Rolleston confirms the observation of Hurst that extract of the thyroid gland given to women suffering from deficiency of thyroid gland secretion, may relieve their constipation; and extract of the pituitary gland, generally of cattle, under certain conditions acts as a powerful stimulant of intestinal movements.
Lack of exercise, Hurst thinks, tends to produce constipation, and Kellogg strongly recommends also certain abdominal exercises (taken up later). Those who lead an active life require more food than those who lead a sedentary life, and the main addition to their diet is in carbohydrates (sugars, starches and cellulose the fiber of vegetables) rather than proteins. Hence active people take a diet which stimulates intestinal movements much more than that taken by inactive people, who consequently tend to become constipated. Want of exercise weakens abdominal muscles which largely control the voluntary part of defecation.
Long continued irritation by purgatives (their effect is produced by irritating the intestinal membrane) with a consequent condition of catarrhal colitis (inflammation of the membrane of the colon) and the use of non-stimulating food leads to a lessened excitability of the intestinal mucous membrane.
Astringents, most frequently in the shape of tea (China tea is the least harmful), exert a similar harmful influence on the intestinal mucous membrane. This constipating effect of tannin (an essential astringent element of tea) is frequent among the poor, who, in addition to eating fresh white bread, instead of whole wheat bread, and potatoes and bananas, that have little residue, in-stead of green vegetables and fruit, diminish the irritability of the intestinal mucous membrane. A cup of black coffee contains even more tannin than a cup of Ceylon tea. With the free addition of milk most of the tannin is rendered inert by combining with casein (the chief protein of milk which is used in cheese) and lactalbumin (milk albuminthe latter word derived from the Latin and meaning the white of egg).
Hypochondria (morbid mental depression) sometimes superinduced by errors of diet, frequently results in a deficient secretion of intestinal juice, as all secretions tend to become diminished in quantity, so that large doses of pilocarpine often fail to produce sweating. One of the most interesting of such cases to be found is given by Hertz (since the war spelled Hurst) as follows:
A medical man (note this fact) aged 45 asked Sir Arbuthnot Lane to remove his colon on account of constipation of several years’ duration, his bowels being open only two or three times a week. Lane had Hurst examine him, as he doubted the wisdom of an operation. The patient looked healthy and had no abdominal pain or tenderness. He was extremely melancholy and said he had suffered ever since his student days from one abnormal condition after another, and he had spent half his life in undergoing cures of various descriptions; that he had had migraine (headache), gastritis (inflammation of the stomach), gastric ulcer, dysentery, mucous colitis (inflammation of mucous membrane of the colon), excess of uric acid (in the urine), renal colic (severe pains caused by any obstruction, frequently “stone,” in the tubular canal leading from the kidney to the bladder), difficulty in passing water and irregularity and palpitation of the heart. He was in the habit of palpating (outlining by feeling and pressing with the palms of the hands and fingers) his abdomen, so that, although his abdominal muscles were quite strong, he could relax them to a remarkable extent, making the examination of his abdomen quite easy. He gave a very detailed description of the condition of his alimentary canal. His stomach, he said, was dilated and extended well below the umbilicus (navel); his transverse colon reached his pelvis (bottom of the abdomen) ; the interior diameter of his colon was normal up to a point two inches below the splenic flexure (see diagram), where there was a funnel-like narrowing leading to the lower part of the descending colon, the interior of which would barely admit the little finger; the sigmoid flexure (see diagram) had disappeared, and the narrow descending colon, coiled round, formed an accumulation similar in structure to the casting thrown up by earthworms.
The cecum and ascending colon were readily felt and appeared to be normal; the transverse colon could not be felt, and the descending colon was found to be contracted, but not more so than is often the case when empty. The rectum was normal.
The patient had been strictly dieting himself for many months, but was now put on an ordinary mixed diet. His bowels had not been open for three days, so on March 31, six ounces of olive oil were injected per rectum and retained during the night. The next morning at 7 o’clock a soap enema was given with a good result.* At 8 a.m. 2 ounces of bismuth oxychloride were taken in bread and milk. (In his later practice Hurst has abandoned the bismuth for barium sulphate, on account of the weight of the bismuth.) At noon the cecum and part of the ascending colon were visible. At 4 p. m. the whole of the ascending colon could be seen. The next morning the near half of the transverse colon, normal in position, was clearly defined and the latter half only contained a little bismuth. April 3 the splenic flexure was reached and a little bismuth was seen in the descending colon. On the fourth morning the cecum, ascending colon, and commencement of the transverse colon were empty, whilst the last half of the latter and the whole of the descending colon were seen. The interior diameter of the latter was no smaller than that of the ascending and transverse colon, so that nothing like the stricture described by this medical patient was really present. The whole series of tracings could, in fact, quite well represent the passage of a bismuth meal through a normal colon if it went through in two days instead of four. A very dramatic incident of this examination, as the author in another publication explains, was permitting the patient, through a proper arrangement of the mirror, to make personal fluoroscopic observation of the functioning of his own intestines and thus effectually ridding his mind of the long persisting hallucination previously entertained by him.
The patient was given plenty of green vegetables and fruit. For a long time stimulating pills, containing aloes and mix vomica, were necessary. There seemed to have been no difficulty in achieving a complete recovery.
A similar case, also of a medical man, a professor in a prominent college, happened in this country recently. He became possessed of the idea that his colon was too long because it did not function as he thought it should. He applied to a surgeon for an operation, was refused, and then was operated on by a Cincinnati surgeon. The patient was dead in three days, although a man in apparently good health at the time of the operation and scarcely over middle age. It may be too charitable to say that the accommodating surgeon made a faulty diagnosis. But Richard C. Cabot has pointed out that in 3000 autopsies in the Massachusetts General Hospital in cases set down as death due to interstitial nephritis (inflammation of the kidney due to infection) over one-half showed no injury of the kidney.
It sometimes happens that several members of a family suffer from infancy with constipation. Hurst says in some such cases this family tendency is the result of neglecting to educate the children in regular habits or of injudiciously dosing them with purgatives.
Another kind of constipation. occurs where people who have always been regular frequently become constipated as they approach old age. Stroup of Nancy, France, found that 23 per cent of 134 men and 39 per cent of 96 women over sixty years old suffered from this chronic condition, which is doubtless increased by the small quantity and bland character of the food often taken in old age and lack of outdoor exercise, which also tends to produce another tendency noted in elderly people of incomplete defecation when it does occur. Thus Stroup found fatty degeneration of the muscle-fibres of the abdominal muscles and the diaphragm (the muscular-membranous partition separating the lung-heart cavity from the abdomen) in each of seven autopsies on bodies over sixty years old.
A marked lessening of the red coloring matter of the blood is often an associated condition. The case is cited of a young woman, aged 21, admitted in July, 1907, who suffered from indigestion, absence of the menstrual flow, shortness of breath, swelling of the ankles and. a feeling of irregular slackness, for five years. With the aid of purgatives the bowels had been opened three or four times a week. On admission the hemoglobin (the leading protein element of the red corpuscles of the blood) was 42 per cent of normal, but red corpuscles slightly in excess. She was given iron and arsenic with general improvement within a week. The hemoglobin rose to 55 per cent. On August 8th, the pills were discontinued in order that the seat of the delay might be ascertained. The cecum was reached 4½ hours after a bismuth break-fast, and the middle of the transverse colon 2 hours later. In the next 24 hours, however, an advance of only two or three inches was made, as the following morning the splenic flexure had not yet been reached, and in the afternoon the shadow was unaltered. Not until the second morning was the pelvic colon reached, the cecum being then no longer visible and the shadow of the ascending colon very faint. The trouble was thus found to be due to the sluggish action of the transverse colon beyond the middle. (The treatment of such cases will be reached in later chapters.)
In fevers intestinal stasis is of frequent occurrence. Suggested causes are the bland character of the food and lessened amount of intestinal juice as a result of both diet and the fever, which impairs secretory activity. There may also be disturbance of bowel activity owing to the presence of poisons in the blood and the high temperature of the body?.
The involuntary exercise of function of the stomach and intestinal tract upon the entrance of food into the stomach causes the chyme (semi-fluid discharges from the stomach) accumulated in the terminal portion of the small intestine to pass into the colon. This effect is the most important stimulus to mass colon movements. These reflexes are most active when a proper quantity of food is taken. A certain amount of intestinal stasis is apt to occur when too little food is taken. The sight, smell, taste and idea of food when an individual is hungry stimulate the movements of the intestines. On the other hand when too little food is eaten because the patient has no appetite as is generally the case in neurasthenic individuals (suffering from nerve exhaustion, insomnia, intense nervous irritability, headache, feeling of constriction in the head, pain in the back, exhaustion after slight exertion, excessive sensibility to noises, irregular heart action, vertigo, dyspepsia), the effect of deficiency in the stomach, small intestine and colon must be particularly well marked. As bearing on the treatment of this class of cases the incident of a young man of 25 is cited. He had used purgatives all his life and was admitted to Guy’s Hospital in September, 1908. It was found that his ordinary diet was of a very bland nature (lack of bulk) rarely containing green vegetables, fruit, brown bread or porridge. The patient was given a bismuth meal on one series of occasions while taking his ordinary diet, and on a second series, after five days, during which he had taken a diet containing porridge and molasses, brown bread, green vegetables, jam and fruit. The bowels were opened by an enema the day before the first series of observations was made; they were also slightly opened on the third morning. On three of the first five days when the stimulating diet was given, the bowels acted spontaneously, and they again acted on the second and third of the three days on which the x-ray observations were made. On the first diet more than six hours were required for the food to reach the beginning of the colon at the cecum; on the second, traces had reached it in four hours. In ten hours the hepatic flexure (bend from ascending to tranverse colon) was reached with the regular diet, but with the stimulating diet the splenic flexure (between the transverse and descending colon), a point rarely passed in this period in any normal individual. In 28 hours a similar difference was observed, the bismuth having reached the pelvic colon with the stimulating diet instead of the end of the trans-verse colon. In 52 hours a good part of the bismuth was still present in the colon with the first diet, but only traces remained of the other. Thus the diet rich in cellulose and sugar had the effect of hastening the passage of the intestinal contents through both the small and large intestines. At the same time it probably produced a more abundant intestinal secretion and allowed a larger growth of benign bacteria in the colon. Consequently sufficient residue was now present in the pelvic colon each morning to form a daily output of normal size. When last seen, about four years later, he said his bowels had opened almost every day.