PATHOLOGY AND DIAGNOSIS OF CONSITPATION. Pathology of constipation is naturally considered under two general heads, namely: (1) Stasis due to altered secretions. (2) Stasis due to mechanical obstruction. The first may be the result of neuroses, and acute fermentative indigestion, or a bacillary infection. The anerobes may attack the contents of the bowel or the gut wall itself, leading to varying degrees of inflammation in the colon, as ulceration, hypertrophic and atrophic catarrh. The colon impaired functionally or traumatically leads to stasis and consecutive inhibition of the fecal excursion. Such impairment further disturbs the physiologic lines of defense against the autointoxications, as (a) The intestinal mucosa, itself; (b) The liver, and (c) The antitoxic glands. Collateral with these phenomena in constipation, are such factors as cholelithiasis, hypochlorhydria, cholangitis and appendicitis, as altered secretions incident to coprostasis. Mechanical obstructions to be reckoned with include: (1) Enteroptosis or Glenard's disease. (4) Certain extramural and intramural sources of obstruction, as pelvic tumors and displacements, nephroptosis, enlarged glands, intussusception, malignant disease, et cetera. (5) Acute angulation at the rectosigmoid junction, hypertrophy of O'Beirne's sphincter, and stiff rectal valves. (6) Disease in the anal canal. Diagnosis resolves itself into an analysis of the above conditions; to differentiate acute or chronic obstruction and the ordinary functional stasis which may also be accompanied by the various forms of colitis. SEQUELAE OF CONSTIPATION, INCLUDING AUTOINTOXICATION. ALFRED J. ZOBEL, M. D., San Francisco, California. This paper treats of many of those conditions which seem to have their origin in chronic constipation with autointoxication. Experimental evidence has not as yet demonstrated that they actually do so, but close observation and clinical experience tend strongly to confirm the theory. All constipated individuals do not necessarily suffer from those symptoms ascribed to autointoxication, yet in the writer's experience most patients with autotoxic symptoms are constipated. This may be without their knowledge, and they often deny in good faith that they are so; but proctoscopic examination generally proves the sigmoid and rectum to be loaded with fecal matter. The proctoscopic observations made on a number of cases of hypertrophic arthritis are mentioned. In almost every instance the lower bowel was found filled with a fecal mass, although most of the patients positively stated that they had had an evacuation within an hour or two previous to the time of examination. Thorough colonic flushings invariably brought about relief from pain, and in time marked improvement in their general condition. These observations are in line with the theory advanced by various authors that arthritis deformans may be due to intestinal autointoxication. Mention is made of the various muscular, arthritic, and neuralgic pains caused by absorption of toxins from the bowel. These are often misunderstood, and treatment instituted for rheumatism. Congestion, irritation, and various disturbances, both functional and organic, of the uterus, tubes and ovaries in the female; the vesicles, urethra, and prostate in the male; and the bladder in both; may result from chronic constipation. This is due both to the proximity of these organs to the lower bowel and to their close physiologic relationship. It is noted that albuminuria may arise from intestinal stasis, and mention is made of the opinion advanced by various clinicians that a nephritis may even be caused thereby. The rôle of constipation with autointoxication as casual factors of epilepsy, neurasthenia, and various mental conditions, as claimed by certain. well known and competent observers, is stated here without comment. The influence of these conditions on the heart, blood-vessels, and the blood; and its effects on the eye, ear, nose and throat are dilated on in this paper, and in support of these statements quotations are culled from the literature that has appeared on this subject during the past five years. The writer further briefly mentions a few more of those conditions that are supposed to arise from chronic constipation with autointoxication, and concludes by agreeing with the trite observation of Boardman Reed that, "when we except the exanthems, malaria, syphilis, tuberculosis, and the diseases caused by traumatisms, by metallic poisons, and by a few other toxic agents or infections from without, practically all the remaining maladies which afflict us and cut short our lives are now directly or indirectly traceable to autointoxication." NONSURGICAL TREATMENT OF CONSTIPATION. DWIGHT H. MURRAY, M. D., Syracuse, New York. Chronic constipation and its results is one of the worst of the foes to a healthful human race. The writer has never known any medication to cure cases of constipation. As primary causes of all cases of constipation, carelessness, ignorance, and laziness are of first importance. The whole medical profession should teach their clientele how to care for themselves, and to train their children in order that constipation may be eliminated by educational and prophylactic methods. Medicines for the use of constipated people have increased until their number is almost countless. Advertisements which extol particular cathartics exploited by this or that pharmacist, are well nigh bewildering. The claim is made that all cathartics finally leave those who use them worse than before. The use of some drugs is not entirely interdicted, as there are cases where they must be used, but almost wholly for temporary relief. A mistaken notion exists in the minds of the laity that the feces is composed largely of debris of food. This, however, furnishes only a comparatively small portion of the fecal mass, the larger portion being deposited in the large intestine as the ash resulting from the products of metabolism. Various exercises, massage, deep breathing, climbing, rowing, electricity, et cetera are helpful in the treatment and cure of these cases. Sigmoid injections of pure olive oil, castor oil, or medicinal paraffin oil are recommended as aids in the treatment. Hours could be spent over the various drugs and methods in detail. After it all we are obliged to say that eternal vigilance as to regularity on the part of the patient must be exercised or a cure will not result. The keynote of this paper is, education and regularity as to periodicity of the first daily stool. The whole profession has a profound duty to perform for mankind in an educational way for emancipating the race. from this insidious foe. THE SURGICAL TREATMENT OF CHRONIC CONSTIPATION. LOUIS J. HIRSCHMAN, M. D., Detroit, Michigan. Constipation is divided into two great classes; the one class being due to a lack of functional activity, that is, dietetic error, improper habit, neural or trophic influences. The other class, which some of us have been pleased to designate as obstipation includes all cases whose impaired activity is due to mechanical interference with the normal peristaltic movements and expulsive function of the bowel. Obstipation, or obstructive constipation may be caused by: (1) The presence of any foreign body, occlusion, contracture, hypertrophy or accumulation in the intestinal canal. (2) Displacements, acute angulations, distentions, neoplasms, adhesions or compressions of the bowel. (3) Developmental defects and congenital deviations from normal. Inasmuch as the surgical treatment of constipation, due to easily recognized local conditions, is obvious, they are dismissed with mere mention. Coloptotic constipation represents such a large percentage of cases of mechanical constipation that its discussion involves the most important field of surgery in the treatment of constipation. All patients. with ptotic colons are not constipated, nor do all constipated patients suffer from coloptosis. There must be in addition to ptosis of the cecum, transverse or sigmoidal colons, a condition of functional inactivity due to atony of the bowel muscle. Suspensions of ptotic colons by means of fixation by adhesions to the abdominal wall are unnatural and interfere with peristalsis. Restoration should be accomplished by shortening the natural support, the mesentery. Lateral anastomoses between the most dependent loops of ptotic bowel is sometimes indicated. Above all, massage, both abdominal and internal rectal, is of primary importance in restoring function, and should be used along with either dietary or hygienic measures to restore bowel function. INTESTINAL STRICTURE FOLLOWING ILEORECTOSTOMY. REPORT OF A CASE. FRANK C. YEOMANS, M. D., New York City. J. X., a man forty-six years of age, was always strong and well but suffered from severe constipation of many years standing. In October, 1909, an anterior sigmoidopexy was proposed for "prolapse of the sigmoid.” Temporary relief followed, but three months later "peritonitis" developed. The same surgeon operated again, freed numerous adhesions, divided the ileum just proximal to the colon, closed the abnormal end and implanted the oral end of the ileum into the rectum. Relief of the constipation was prompt but when he first consulted me, in July, 1910, it had returned in an obstinate form with all the symptoms of a marked autotoxemia superadded. The proctoscope passed easily, but no opening could be discovered in the rectum or the sigmoid. An excellent radiograph, by Doctor L. G. Cole, proved the colon and sigmoid to be unobstructed. Concluding that the feces, following the path of least resistance, were accumulating in the colon, I did an appendicostomy at the New York Polyclinic Hospital, December 16, 1910. Irrigations through the appendix relieved all symptoms for ten weeks. Constipation and toxemia then returned, however, and exploratory laparotomy was performed on March 14, 1911. The ileum ran down into the left side of the pelvis and was lost in a mass of dense adhesions. A broad lateral anastomosis was made between the ileum, just above the adhesions, and the sigmoid. The patient reacted well from the operation, but developed a double pneumonia, eighteen hours later, to which he succumbed on the fifth day. The urine was suppressed the last twenty-four hours of his life. The bowels moved on the second day, and, thereafter, three or four times daily. At the autopsy no peritonitis was found. The specimen removed, consisting of ileum, sigmoid, and rectum intact, showed perfect union of the recent lateral ileosigmoidostomy. The remarkable feature of the old end-to-side ileorectostomy was that the opening was so constricted that it would scarcely admit a number 16 French catheter and physiologically amounted to a stricture. The noteworthy features of this case are: (1) Reverse peristalsis of the colon, evidenced by the large quantities of feces expelled by the irrigations through the appendicostomy. (2) The radiograph was valuable in demonstrating a patent sigmoid and colon, thereby proving that the obstruction was in the small intestine. (3) Failure of the proctoscope to reveal the site of the opening does not discredit the diagnostic value of that instrument but shows the extreme degree of contraction of the opening. (4) The many actions of the bowel signify clearly that the physiologic function would have been permanently restored had the patient survived the pneumonia. The practical lesson derived from a study of the case is that lateral anastomosis is superior to end-to-side union, especially in the presence of inflammation. [TO BE CONTINUED.] AN ADDRESS TO THE NURSES OF THE GRADUATING CLASS AT THE MICHIGAN ASYLUM.* REUBEN PETERSON, A. B., M. D. PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN. I DESIRE to express my appreciation of the honor conferred upon me in being asked to address you this evening. Not only is it an honor but it is a real pleasure. For it affords me another opportunity of stating publicly, what many times during the year I express privately, the obligations I am under to trained nurses and how impossible it would be for me to practice my profession without them. For many years I have been interested in this excellent training school. Some fifteen years ago I had the privilege of delivering some lectures here to the nurses. At that time, my friend, Doctor Edwards, was superintendent of the Asylum and I can remember the conversations we had as to the best course for a training school of this description. He felt his responsibility toward the young women who were giving two of their most valuable years to the acquisition of the principles of nursing and wanted to do the best he could for them. Since Doctor Edwards' untimely death, your school has been exceptionally fortunate in those who have controlled its policies. I trust that I may not be accused of having acquired the obstetrician's habit of telling the fond parents that the latest arrival is certainly the finest specimen he has ever seen, when I tell you that I am informed upon what I consider good authority, that your training school is the best of its kind in the state. To follow this up, since Michigan is the best state in the Union, and since there is no country in the world to be compared with this, you can easily estimate the rank of the school from which you are graduating this evening. You are starting forth upon the practice of your profession at an exceptionally interesting period in the history of trained nursing. The struggling days of the profession in one sense are over. Trained nursing *Delivered at Kalamazoo, Michigan, June 6, 1911. |