Mysteries Of The Intestine
( Originally Published Early 1925 )
Hurst is of the opinion that unfortunately it is not possible to make a diagnosis of intestinal stasis (constipation) from symptoms alone. The worst case he has ever seen of intestinal toxemia (poisoning), with the classical symptoms of extreme emaciation, extensive pigmentation, evil-smelling sweat and cold extremities, was not due to chronic intestinal stasis but to chronic diarrhea, the result of some obscure infection, contracted by a lady while game hunting in Africa.
One who is suffering from chronic intestinal stasis should as a first step carefully locate the seat of the trouble. The best practice is to have a bottle of 100 large charcoal tablets (5 grains each) in plain view where it will act as a frequent reminder. As a first trial chew and swallow four of them and wash down immediately after dinner. If this charcoal is out the next morning, and does not keep on coming out for two or three days thereafter, the patient is in excellent condition as to stasis. If conditions are unsatisfactory the interval between taking the charcoal marker and its reappearance must be lengthened by taking it earlier in the day until the efficiency of the colon is fully and accurately deter-mined. Hurst says if the charcoal is taken at 4 p. m. and some of it is not passed at the latest on the second morning the patient must be regarded as constipated.
This English view will not be accepted by Kellogg, for instance, who insists that there should be an action of the bowels after every meal, with an additional one at night if possible. Whether this view is accepted or not there is little doubt of the non-acceptance of the Hurst theory by people of fastidious personal habits. The taking of a charcoal marker should be a common practice, at least as frequently as there is such loss of appetite and lack of energy as is indicative of impaired intestinal function. Thus many people will learn with great surprise that regularity is frequently very far from being the same condition as intestinal efficiency. This excellent first step, however, has the great disadvantage of giving no indication as to the part of the colon in which the stasis occurs. Although the fluoroscope is nearly always used for the purpose of obtaining this information (as discussed elsewhere in this chapter) yet it can be obtained with some accuracy in people who are not fat by palpation (feeling) with the fingers along the course of the colon. In such cases the transverse colon will nearly always be found well below the umbilicus (navel) and near this point hard masses are apt to be felt and thus located? If the rectum is at fault a small irrigation of cool water should promptly relieve it. If the colon is tender under slight pressure, such line of tenderness may indicate its course in a general way.
The two points at which the stasis is most apt to occur are in the region of the cecum (beginning of the colon) and the lower or distal part of the bowel. The first named location is called colic constipation and the latter, dyschezia.
There is but one method uniformly accepted by the best authorities, of which Hurst is an excellent example, in locating the point of stasis accurately, and that is by means of the fluoroscope and barium sulphate meal, which is opaque to the x-rays. The fluoroscope is an instrument for holding the fluorescent screen in x-ray examination. No skiagram, or printed x-ray picture, is recommended. With the fluorescent screen the condition, as the meal progresses, is brought under observation and the outline of the colon can be then traced on a piece of leaded glass placed over the screen from which it can be copied.
Although barium meals are the best means of obtaining information of the motor functions of the colon, barium enemata generally give earlier and more exact information concerning the possible presence of a stricture, displacement or distention. This is especially the case with stricture of the pelvic colon (lower part of the descending colon), which cannot always be satisfactorily examined by the former method.
Several authorities have uttered warnings against unscientific and incompetent use of the x-rays in the examination of intestinal stasis. Hurst says in a recent discussion at a London medical society cases were related by various speakers in which a diagnosis of intestinal stasis was made, although the time at which different parts of the bowel were reached by the barium meal fell well within normal. Thus one speaker concluded that the presence of bismuth between the hepatic flexure and pelvic colon (see diagram) thirteen hours after the meal in one of his cases suggested some mechanical difficulty in the left iliac fossa (the pelvic colon). It would be rare to find less evidence of stasis in a normal individual.
All figures as to the progress of a barium meal in normal individuals are based on averages, and an average must not be taken as a figure to which all must comply in order to be considered normal. In calling attention to frequent errors caused by a wrong deduction from average figures Hurst says that in fifty-eight healthy individuals examined by Alan Newton seven hours after a bismuth meal, the furthest point reached by the bismuth was the cecum in four patients, the ascending colon or hepatic flexure in twelve, the transverse colon or splenic flexure in thirty-one and the descending or pelvic colon in eleven. Though the average furthest point is the transverse colon, it would be clearly incorrect to say that stasis was present in an individual in whom the bismuth had not reached beyond the hepatic flexure after seven hours.