( Originally Published Early 1925 )
Goodhart of London, consulting physician to Guy's Hospital, first used the phrase "greedy colon." In a lecture delivered in 19021 he made this observation: "I have no doubt in my own mind that this absorbing organ (the colon) is much more active in some than in others and that when greedy the colon, by rejecting so little, is a cause of constipation." This Goodhart theory has grown in importance because, if correct, it explains the presence of dry impacted feces in so many cases.
Hurst remarks the unusually complete digestion of food in some cases as being particularly noticeable when articles of diet containing large proportions of cellulose, such as raw vegetables, raw fruit and mushrooms are consumed. In normal individuals they are only digested to a slight extent, but in cases of greedy colons they are more or less completely absorbed, the intestines appearing to possess the power of digesting a considerable quantity of cellulose and even of the semi-cellulose of agar. According to Adolf Schmidt, quoted by Hurst, the stools of the greedy colon are strikingly different from the dry, hard stools which are passed as a result of taking opium and from patients suffering from dyschezia (in the lower part of the colon), as these contain obvious vegetable refuse and are of normal constitution, except for the small quantity of water present. This, however, only shows that very little digestion can take place in the rectum, as the constipating action of opium appears to be chiefly due to a diminution in rectal sensibility with the consequent development of dyschezia. Frequently the greedy habit of the colon is acquired, as in the following case, cited by Hurst:
Margery W., a governess, 23 years old, was admitted into Guy's Hospital under Dr. Newton Pitt in November, 1908, for severe constipation following an attack of diphtheritic paralysis when she was 18. For five years she had no desire to defecate and had never opened the bowels oftener than once in five days in spite of the daily use of cascara sagrada. The stools were semi-fluid. Though she felt tired and subject to headaches she was well nourished and her color was good. On admission her tongue was furred and her breath offensive. The rectum was completely empty and no accumulation could be felt in the colon, although the bowels had scarcely been opened at all for more than three weeks. Purgatives were ineffective and enemata never brought away more than a very small quantity of material.
The x-rays showed that the passage through the intestines was at the normal rate. This agreed with the patient's history, that her bowels rarely opened oftener than once in five days and that then only a small quantity was passed. It was clear, therefore, that she had an exceedingly greedy colon, absorption being so active that by the time the pelvic colon was reached hardly any residue was left. The proportion of bacteria in the feces was found to be about normal. This view explains the complete failure of purgatives, as they merely hastened the passage of the small quantity of contents, which already moved with sufficient rapidity.
The patient was given three drams of a mixture (principally agar) every day, in order to increase the bulk, for ten days without appreciable effect. Two days after the regulin was discontinued the patient's mouth temperature suddenly rose at 2.30 p. m. to 110° and she felt extremely ill. She was sponged and it fell to 101° but rose again to 111.4° at 5.30. At 6.15 it had fallen to 97.6°. At 8 p. m. it again rose for a few minutes to 104.° It remained normal until the next morning, when it rose in a half hour to 108° from which it fell in a few minutes to normal and did not rise again. The theory advanced by Dr. Pitt, in charge, was that the agar with the intestinal juice formed an unusually good culture-medium for intestinal bacteria and that the high temperature was due to intestinal poisoning. After a month the amount of feces passed each week with the aid of enemata, but without regulin, amounted in quantity to but a normal stool. Examination of the results of the enemata showed that during a first period of 12 days she passed 4.3 grams of dried feces (1 gram = about 15 1/2 grains, about 31 grams to an ounce) or 0.36 grams per diem, and during a second period of 8 days 5.1 grams, or 0.64 grams per diem. During the next 3 days she took 12 grams of agar a day, but only passed 3.9 grams, or 1.3 grams a day. On the diet she was taking a normal individual would pass about 40 grams of dried feces a day.
Several months after the patient left the hospital she improved somewhat and for several months had a small passage every two or three days. In 1914 she had a course of treatment with diathermy (local rise of temperature produced by a form of high-frequency electric current *) which did her good for a time. In 1915, after an accident to her arm, she began to pass blood and mucus and her constipation became worse. In November, Sir Arbuthnot Lane removed part of her colon. She did very well until February, 1916, when severe pain and sickness developed. A second operation was per-formed, several adhesions (bands attached probably to colon) divided and some small glands removed. For two months she had septic trouble in her throat, gums and breasts, but from August (until she was heard from last in November, 1917) she was very well, indeed. Her bowels acted daily, she had no pain and felt better than she had done for years, being able to do light duty in the nursing home where she had lived since her first operation.
The good result in this operation needs to be supplemented by our author's opinion, expressed elsewhere, on the general subject of colon surgery: "When constipation is the result of definite organic obstruction, surgical treatment is clearly indicated. But various operations have been recommended in the last ten years for the relief of constipation in the absence of this clear indication, and the results obtained have only been satisfactory in a comparatively small proportion of cases. Though I have sometimes seen extremely gratifying results follow the surgical treatment of constipation, it has, to my knowledge, been the direct cause of deaths in several eases, and I have been consulted by patients whose condition afterwards was either no better or actually worse."
One of the best authorities in this country says that in bringing forward (in a notable book on surgery) the subject of displaced abdominal organs and stasis we are opening one of the most dangerous fields for surgical abuses at the hands of the surgical "confidence man" who needs no other excuse for performing a surgical operation than the consent of the patient. X-ray observation is of inestimable value in the study of these cases, but the most dangerous agent yet placed at the disposal of the unscrupulous surgeon, because it is so convincing to the patient and at the same time so meaningless when considered independently of the history of the ease and not properly interpreted. This warning is necessary because there are more people afflicted with such defects than with any other disease known to humankind, the percentage reaching to fully one person in five of potential sufferers from abdominal organs displaced downward.'
Dr. Charles H. Mayo, the toted surgeon of Rochester, Minnesota, in an address in Cincinnati in 1923, as re-ported in the press, registered his opposition to the much too frequent use of the knife by surgeons. He pointed out that the body is weakened by operations and they should never be resorted to except in cases of absolute necessity.
Everyone knows, says a distinguished English authority and surgeon, the frequency of displaced abdominal organs, of loose kidneys, of the flaccid mid-section of the abdomen (epigastrium) and bulging below. Constipation seems a heritage of every race. Here is material in abundance for the surgical adventurer. Regardless of all else the stomach may be lifted and fixed by suture (stitches), the kidney anchored to the last rib, and constipation relieved for the moment by a short-circuiting or abstracting operation (cutting out by the surgeon). The lot of patients is hard. Constipation will soon re-turn, the other kidney will fall down or the anchored one break loose, and the distress of the stomach greatly exceed that of its vagrant days. That is the tale of reckless surgery. There are few subjects in medicine so greatly in need of the best services that pathologists (who deal with the nature of disease), physicians and surgeons alike can give.
The investigation of the case just reported in detail shows that the constipation of patients with a greedy colon may be simply the result of excessive digestion and diminished residue. The normal action of the intestinal tract since her colon was removed showed, in the opinion of Hurst, that it was responsible for the excessive absorption and that the small intestine continued to act normally.
This form of stasis is frequently associated with excessive acidity of the stomach. In a series of 100 cases of habitual constipation, taken from the records without any attempts at selection, 87 showed increased gastric acidity. On the other hand in diarrhea analysis of the stomach contents regularly showed decreased acidity. Strasburger believes that the strong disinfectant influence of the increased hydrochloric acid (an important constituent of the gastric juice) causes increased digestion, with smaller food residue, and sterilization of the food, thereby diminishing the growth of bacteria with absence of putrefactive odors and lessened bowel movement with consequent constipation. Microscopic examination usually discloses the residue to be mostly detritus (fragments) .
Russell divides practically all forms of gastric disorders into two classes—excessive and deficient hydrochloric acid—a very important observation .
Reverting to the subject of this chapter the reader should note that excessive colon digestion or absorption can be of many degrees of development. In a large percentage of cases, especially where the trouble is in its early stages, the facts cited are of great importance because it is then that a cure or amelioration can be most easily effected. The subject is an interesting one as showing a probable explanation of a series of puzzling conditions present in many cases of constipation. Strasburger prints the following table showing in grams the colon output of six individuals, three normal and three constipated, all kept on the same diet.
Thus each of the three chief constituents (food-residue, moisture and bacteria) is diminished in constipation.
As diminished residue is a condition in nearly all forms of intestinal stasis the reflecting reader will note the manifest importance of avoiding such an unnatural disposition of the material by absorption.