Commonest Form Of Stasis
( Originally Published Early 1925 )
As the intestinal contents pass downward they carry with them the flora (micro-organic plant life) from a higher level, but if the conditions are not favorable for their growth they quickly give way to more adapted types. In the lower part of the colon, due to the gradual loss of water, there is a marked decrease in the number of live micro-organisms and those that remain are incapable of further growth. It is estimated that from 5 to 8 drams of bacteria, mostly dead, are excreted each day, (8 to an apothecary's ounce).
Dyschesia is a derangement of the functions of the lower end of the great bowel. It is the most common of all forms of constipation, the most ordinary effect being imperfect action. Hence, although the bowels may be opened daily the contents become unduly hard owing to the excessive absorption of water during their long retention. In severe cases defecation is not only incomplete but it does not occur daily and finally it may become quite impossible for the bowel to function with-out mechanical assistance. The pelvic colon can often be felt through the front wall of the rectum to be filled and in some cases a further accumulation is found by abdominal palpation (with finger tips) in the iliac (left flank) and even in the descending colon (above). Occasionally the dyschezia is due to inability to pass the contents of the pelvic colon into the rectum, the evacuation from the latter offering no difficulty. In such cases the rectum is found to be empty; but the impacted con-tents in the pelvic colon can generally be felt as an elongated tumor through the front wall of the rectum. As a similar accumulation may occur in the rare but important cases where ,the slowing up begins farther back in the colon, the question as to which of the two forms is present can only be answered by the x-rays?
As the activity of the colon as far as the splenic flexure (bend from transverse to descending colon) and below in uncomplicated cases of dyschezia is normal (an important point to note) treatment by diet and purgatives is always ineffective because they expend their force in the upper part of the bowel which is functioning properly?
Chevalier, was the first to describe this type of stasis and explained how enemata are the only proper treatment, as with purgatives "the whole intestinal canal is teased and pained for the defective action of that very part of it which is remote from their influence."
The causes of dyschezia are not far to seek. When the lower end of the bowel is filled to the point of impaction the muscular coat becomes more and more relaxed, distended and weakened to the point where it loses the power to contract against the dry and semi-solid mass that requires expulsion. In some cases the impaction extends to the pelvic colon, in consequence of which its muscular coat undergoes similar changes. The desire is lost so that the patient has succeeded in completely deranging nature's very important functions for the colon discharge of the refuse of the body. In extreme cases the blunting of the muscle sense may develop to the point where the introduction of the enema may not produce even an artificial call to defecation?
This call is habitually disregarded for various reasons, the most frequent of which are ignorance and laziness. Regularity of this habit should be taught with the greatest care from early infancy. Surgeon-Colonel J. G. Pilcher of the British occupation forces in India reports that the rarity of constipation among the natives of India is largely due to the fact that the habit of defecating at an early hour in the morning is universally taught. The Indian mother supports the buttocks of her infant on the mother's big toes, so that it can defecate between her feet. As soon as the child can walk it accompanies its mother to the jungle at or before sunrise. The result of this teaching is seen in the Indian prisons. The moment the dormitories are open at sunrise every prisoner rushes to the latrine, and by 8 a. m. the whole proceeding for 2,000 persons is ended and the material removed and trenched in the prison garden. Constipation is also unknown among children in China and Japan owing to the excellent training infants undergo from birth. When it wakes in the morning the mother supports its buttocks in her hands and holds it erect with its back firmly against her breast in which position she presses its thighs against its abdomen?
Hurst gives a typical case of dyschezia. Mabel, T., aged 17, had suffered from dyschezia since she was 10 years old. As a little girl she had no time to attend to this call of nature before going to school, and when there she was too shy to ask for permission to retire. At 15, when she began work as a dressmaker she had be-come very constipated, but with the aid of medicine kept her bowels open every other day. Unfortunately the desire came in the morning, when it did come, while she was at work. If she retired she required so much time that it became a subject of remark so that she no longer obeyed the call. This gradually became weaker and the difficulties increased. She now attended to this duty but twice a week. She was occasionally sick, her appetite was poor and she always felt slack and unequal to doing any work. The troubles reached a crisis in February, 1907, when she was admitted to Guy's Hospital after a period of bowel inaction lasting five weeks. Her abdomen was somewhat distended and tender, her tongue dry and furred and she vomited occasionally. She was given an enema at once and various purgatives tried but the bowels were only opened when an enema was given. After her discharge she was treated with electrical massage but with no improvement, so on May 24 she was readmitted. She complained of pain in the abdomen, she was occasionally sick, had a poor appetite, her complexion was sallow and her expression apathetic. Her bowels were opened by enema May 25. After this she was given a full diet but no medicine. Her bowels were not opened again until May 28. On May 27, 1907, she was given a bismuth breakfast, this being the first occasion on which a case of constipation was ever examined with the x-rays. In four hours the shadow of the cecum and the whole ascending colon was distinctly visible on the fluorescent screen (fluoroscope). Ten hours after the breakfast the shadow of the' large intestine from the cecum to the end of the iliac colon (sigmoid flexure) was visible. The next morning after 28 hours, it had all accumulated in the greatly distended pelvic colon and rectum, except a small quantity which was still present in the ascending colon. Thus the pas-sage through the small intestine and colon was rapid rather than slow. On the afternoon of May 28, the day after the bismuth meal was taken, the rectum was found to be dilated and completely filled with hard feces, but there was no inclination to defecate and she was unable to do so. The contents were broken up and an enema given when a large quantity was evacuated which greatly relieved the abdominal pain. The next morning another enema was given but with a less result than on the pre-ceding evening. No trace of the bismuth could now be seen, showing that the enemata had removed all the bismuth from the colon.
The patient's condition must have been due to paresis (partial paralysis) of the muscles of the pelvic colon and rectum, brought about by their over-distension, as the remainder of the colon was normal, the diaphragm moved well and the abdominal muscles were moderately strong. The patient was thus suffering from dyschezia. The rapid passage through the small intestine and colon was analogous to that occurring with an organic obstruction, being due to the increased activity of the bowel in its attempt to overcome the obstruction in the pelvic colon and rectum. After May 29 an enema was given every day to June 11. In 4 hours after a bismuth break-fast the cecum and a small part of the ascending colon were seen through the fluorescent screen and 4 1/2 hours later the cecum, ascending colon, and most of the transverse colon were visible. The next morning no enema was given, and at 11 a. m. most of the large intestine from the cecum to the beginning of the pelvic colon could be seen. At 5 p. m. the pelvic colon was also visible, and was found to be no longer distended. On June 13, at 6 a. m., 48 hours after the bismuth breakfast, an enema was given with a good result. At 10 a. m. no bismuth shadow was visible. These observations showed that the pelvic colon was no longer distended and that with the removal of the obstruction, the stimulus to in-creased activity of the colon had gone, as the bismuth no longer passed at an abnormally rapid rate through the intestines.
The patient was now almost completely free from pain and looked and felt much better than she had done for many months. An attempt was made to hasten the recovery of the tone of the pelvic colon and rectum by means of intra-rectal electrical treatment. This had no appreciable effect and was discontinued after ten days. The patient was then discharged and her mother instructed as to proper diet and asked to encourage her to try and open the bowels every day without artificial assistance. If she failed an enema was to be given.
The patient was seen at intervals until 1912. She looked and felt much better though she was still quite unable to escape the use of the enema. This had only failed to act on a few occasions. Thus on April 19, 1908, she came to the hospital to say that her bowels had not been open for 24 days. In spite of this she did not look ill, but she complained of considerable abdominal pain and tenderness. The rectum was found to be greatly distended but nothing could be felt in the descending or iliac colon. She was accordingly readmitted. Six ounces of olive oil were injected in the evening and retained during the night. The next morning an enema higher than usual produced a large evacuation. The following morning an ordinary enema was found to be equally effective. It seems probable that this attack was due to the inefficient administration of the enema at home.
The reader should note here that the main reliance in this severe case of dyschezia was on the enema. Nothing else was done that succeeded in lessening the formidable character of the obstruction with which the physician had to deal.