Constipation in adults and children, with special reference to habitual constipation and its most successful treatment by the mechanical methods
MC^:<v;. -'■'" KT.'-tt.,' ";v -<.;-. 3T2- CORNELL UNIVERSITY. f THE HostucU |J. Wltxvazv Cibrarg THE GIFT OF ROSWELL P. FLOWER FOR THE USE OF THE N. Y. STATE VETERINARY COLLEGE. 1897 CORNELL UNIVERSITY LIBRARY 3 1924 104 225 192 The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924104225192 CONSTIPATION IN ADULTS AND CHILDREN (From Luschka, "Die Lage der Bauchorgane," etc.) Frontispiece. 19, Right lobe of the liver ; 20, Quadrate lobe ; 21, Left lobe of the liver ; 22, The suspensory (broad) ligament of the liver, cut off; 22*, Fundus of the gall-bladder; 23, Oesophageal (upper) orifice of the stomach ; 24, Cul-de-sae of the stomach, partly overlaid by the left lung ; 25, Pyloric end of the stomach ; 26, Section of the stomach which lies in the epigastrium, and is partly covered by the liver ; 26*, Arteria gastro- epiploica dextra, corresponding to the course of the greater curvature of the stomach ; 27, Caecum ; 28, Appendix Vermiformis ; 29, Ascending colon ; 30, Right colic flexure ; 31, Transverse colon ; 32, Left colic flexure ; 33, Descending colon ; 34, Dotted lines, showing position of sigmoid flexure underneath the small intestines ; 35, Small intes- tines in the arrangement most commonly found; 36, Obliquely ascending end of small intestines ; 37, Summit (apex) of bladder covered by peritoneum ; 38, Anterior and lower portion of bladder (in a state of moderate distention and reaching beyond upper border of pelvis) free from peritoneum. •The. CONSTIPATION IN ADULTS AND CHILDREN WITH SPECIAL REFERENCE TO HABITUAL CONSTIPATION AND ITS MOST SUCCESSFUL TREATMENT BY THE MECHANICAL METHODS BY H. ILLOWAY, M.D. FORMERLY PROFESSOR OF THE DISEASES OF CHILDREN, CINCINNATI COLLEGE OF MEDICINE AND SURGERY ; FORMERLY VISITING PHYSICIAN TO THE JEWISH HOSPITAL, CINCINNATI; ETC., ETC. MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK OF THE NEW YORK COUNTY MEDICAL ASSOCIATION, ETC. "Mtia ftotft THE MACMILLAN COMPANY LONDON: MACMILLAN & CO., Ltd. 1897 All rights reserved La 31 6 * Copyright, 1897, By THE MACMILLAN COMPANY. /ec Nortoaoti ^ress J. S. Cushing & Co- — Berwick ft Smith Norwood Mass. U.S.A. TABLE OF CONTENTS Paet I SECTION I CHAPTER I TO PAGE Anatomy of the Intestines. (With reference mainly to the large bowel ; its position in the abdominal cavity ; the internal arrange- ment of its mucous membrane.) The vessels. The nerves — show- ing the relation of the bowels to the cerebral and the spinal centres 27 CHAPTER II Flatus 30 CHAPTER HI Intestinal Peristalsis. Defecation ....... 39 CHAPTER IV Faeces (appearance thereof under the microscope) .... 42 CHAPTER V Definition; Etiology; Classification 46 CHAPTER VI Acute Constipation ; Etiology. (En parenthese, an account of for- eign bodies that may cause such, with histories of cases to illustrate the mode of treatment when sharp bodies, as knives, etc., have been introduced) 56 CHAPTER VII Chronic Constipation ; Etiology. The various maladies that may give rise thereto — Foreign bodies (with histories of cases) — Mal- formations of the intestines — Dislocation of the intestine — Essen- tial primary atrophy of the intestine 87 viii TABLE OP CONTENTS CHAPTER VIII TO PAGE Spastic Constipation. Enterospasm — Enterospasm and atony — Spasmodic stricture of the rectum — Spasmodic contraction of the sphincter of the anus without fissure — Irritable sphincter . . 94 CHAPTER IX Atony of the Intestine. Causes — Mode of action . . . 105 CHAPTER X Symptomatology. General and local symptoms . . . .112 CHAPTER XI Diagnosis. Methods of examination ; percussion, palpation, inflation — Faeces, microscopic examination of. Prognosis 132 CHAPTER XII The Consequences of Constipation. Haemorrhoids — Anal Fis- sure — Typhlitis — Appendicitis — Enteritis membranacea — Proc- titis— Faecal tumors — Dislocation of the bowel — Ulceration of the bowel — Ulceration with hypertrophy — Diverticula . . 166 CHAPTER XIII The Consequences of Constipation, Cont. Diarrhoea with consti- pation — Ileus — Jaundice — Torpid liver — Atony of the stomach — Auto-intoxication 176 CHAPTER XIV The Consequences of Constipation, Cont. Disturbances of the nervous system — Pyschoses — * * * — Chlorosis . . . 185 SECTION II— TREATMENT CHAPTER XV Treatment of Constipation due to Atony of the Intestine. Hygienic rules — Dietary regulations ; diet list — Exercise ; rules for same 203 CHAPTER XVI Treatment of Constipation due to Atony, Cont. Massage ; gen- eral technic of — Special manipulations — Schedules of manipu- lations— Duration of treatment — Instrumental massage . . 243 TABLE OF CONTENTS ix CHAPTER XVII TO PAGE Treatment of Constipation due to Atony, Cont. Swedish move- ments— Machine gymnastics — Contra-indication to massage . 264 CHAPTER XVIII Hydrotherapy. Special procedures — Schedule of temperatures for water 283 CHAPTER XIX Electricity. Modes of application 299 CHAPTER XX Medicines. Nux vomica (Strychnia) — Calabar bean (Physostigma) — Ergot — Zinc — Ammonii chloridum 305 CHAPTER XXI Effects of Treatment ; Complication ...... 308 CHAPTER XXII Treatment of Conditions related to Atony. Ileus — Paraly- sis of the intestine — Atony of the rectum 317 CHAPTER XXIII Treatment of Atony of the Intestine dependent upon Morbid Processes. I. Constipation dependent upon intestinal catarrh — II. Atony from morbid processes elsewhere: 1. Neurasthenia ; 2. Debility after protracted maladies ; 3. Disease of the heart . 324 CHAPTER XXIV Treatment of Spastic Constipation 333 CHAPTER XXV Treatment of Constipation due to Irritable Rectum . . 340 CHAPTER XXVI Treatment of Constipation dependent upon Genito-urinary Troubles 343 CHAPTER XXVII Fissure of the Anus 345 X TABLE OF CONTENTS CHAPTER XXVIII TO PAGE Hemorrhoids. Relief of the constipation due to them — Non-surgi- cal treatment of 353 CHAPTER XXIX Oil Injections. Technic of 359 CHAPTER XXX Other Methods of Treating Constipation (recommended by various writers). 1. Stretching of the sphincter ani ; 2. Applica- tion of boracic acid to the anus ; 3. Treatment by river-gravel (Flusskiesel) ; 4. By suggestion 365 CHAPTER XXXI Treatment or Constipation in Old People 369 CHAPTER XXXII Formulary 383 Part II CONSTIPATION IN INFANTS AND CHILDREN CHAPTER I Introduction ; Classification. Congenital Constipation. Malformation of the rectum and anus — Of the colon — Of the small intestines — Malplacement . . 412 CHAPTER H Acquired Constipation. Acute Constipation, Etiology 418 CHAPTER III Chronic Constipaton, Etiology 422 CHAPTER IV Habitual Constipation, Etiology . 428 TABLE OF CONTENTS XI CHAPTER V TO PAGE Habitual Constipation dub to Atony, Cord. .... 434 CHAPTER VI Habitual Constipation due to Atony, Cont. Habitual constipa- tion in older children 437 CHAPTER VII Symptoms and Diagnosis 440 CHAPTER VHI Treatment of Constipation due to Atony of the Intestine (Infants). General measures — Special measures (remedies, injec- tions) — Massage — Secondary measures 455 CHAPTER IX Treatment of Constipation due to Atony of the Intestine, Cont. Older children 458 CHAPTER X Some Anatomical Considerations ....... 464 CHAPTER XI Massage. Preliminary considerations ....... 469 CHAPTER XII Massage. Technic of manipulations for infants and young children 480 CHAPTER XIII Spastic Constipation. Fissure of the Anus 484 CHAPTER XIV Formulary 488 LIST OF ILLUSTRATIONS Part I PAGE Frontispiece, showing the abdominal organs in position. The duodenum and surrounding structures 4 The cascum, showing funnel-shaped terminal extremity of the ileum, and the appendix vermiformis 7 The large bowel in position g The caecum laid open, showing orifice of appendix vermiformis. 10 The sigmoid flexure 12 The sigmoid flexure 13 The external sphincter of the anus, perineal muscles in man ... 15 Sacculi Horneri 18 Diagram of the nerves of the intestinal tract 21 The plexus of Auerbach. 23 The plexus of Meissner 24 The male perineum, showing distribution of nerves .... 25 Normal faeces 41 Human colon, congenital giant growth 67 Diverticulum, congenital, of the sigmoid flexure 77 Illustration of enteroptosis 80 Upward dislocation of transverse colon 81 Dislocation of the sigmoid flexure to the right 85 Abdomen, where to examine 119 Arrangement of apparatus for inflating the bowel with gas. .122 Arrangement of apparatus for inflating the bowel with air. 123 Crystals of hesmatoidin 127 Teichmann's hasmin crystals 127 Colored Plate, showing microscopic appearance of some constipated fasces, between pages 128 and 129 Demi-schematic view of the external surface of the ampulla of the rectum 133 xiii xiv LIST OF ILLUSTRATIONS PAGE Demi-schematic view of the internal surface of the ampulla of the rectum False diverticula, of the large bowel 163 Distention diverticula, of the small intestine 16i Diverticulum of the ileum *°° Bandages for the abdomen 2CU Abdominal bandage 202 Effleurage with the tips of the fingers 207 Frictions with the thumb 207 Petrissage with the thumb 208 Petrissage with the thumb and finger 2°9 Diagrammatic illustration of position of patient for massage. ■ 212 Division of the belly with one hand 21* Division of the belly with two hands 215 Rolling of the belly with one hand 216 Rolling of the belly with two hands • • -216 Petrissage of the abdominal walls 217 TheKammgriff 218 Kneading of the belly 219 Punctation 219 Circular effleurage 220 Position of hands for operator 221 To break up indurated faeces in caecum and ascending colon. 222 To break up indurated faeces in transverse colon 223 Manipulation for ascending colon, liver, and gall bladder. 225 Transfer movement, for caecum and ascending colon .... 227 Transfer movement, for transverse colon 228 Transfer movement, for descending colon and sigmoid flexure. 229 Position of- hands for petrissage, of sections of colon .... 230 Position of hands for petrissage, of sections of colon. Frontispiece II. Same, showing large bowel, liver, and stomach. Congenital contraction of the ascending and transverse colon, etc Congenital obliteration of the small intestines. Ileum with diaphragms . . . .. The abdominal viscera of a new-born infant held in Diagram of the above Diagram showing direction of manipulation Manipulation II. for infants .... Diagram showing direction of manipulation Manipulation III. for infants .... Manipulation IX. , thumb movement. position 395 401 407 462 463 471 471 472 473 476 PART I CONSTIPATION IN ADULTS \ CONSTIPATION m ADULTS °!<K» SECTION I CHAPTER I ANATOMY OF THE INTESTINES The part of the human body that principally concerns us here is the intestinal canal, consisting of two distinct and characteristic parts, — the small intestines and the large bowel. The small intestines constitute by far the major part of the intestinal tract. The average length in the adult male (between the ages of twenty and fifty) is twenty-two feet, six inches ; in the female it is twenty-two feet, four inches. Exceptionally it is found, both in the male and female, longer or shorter by some feet. The intestinal tract proper begins at the stomach, from which it is separated by the sulcus pyloricus, with that portion known as the duodenum. Ever since the days of Herophilus the small intestines have been divided into three parts, — the duodenum (twelve fingers, eight to ten inches), the jejunum, and the ileum. There is, how- ever, no line of demarcation that separates the duodenum from the jejunum, or any distinctive feature by which to 3 4 CONSTIPATION IN ADULTS recognize the one from the other. Luschka has therefore proposed that the duodenum and jejunum be grouped together as one part and be called the pancreatico-bilious intestine (intestinum pancreatico-biliosum). The duodenum takes its origin at the pyloric extremity of the stomach, on the right side of the epigastrium, about the level of the last dorsal vertebra, and ends on The Duodenum and surrounding Structures. (Sappey.) 1, Pars horizontalis superior, thrown back to the right; 2, Pars descendens oz verticalis ; 3, Pars horizontalis inferior. the left of the spinal column, about the level of the third lumbar vertebra, in the jejunum. Between the points here described it changes its course three times and is therefore divided into three segments, — some have it four, — the pars horizontalis superior, the pars descendens or verticalis, and the pars horizontalis inferior. The fourth part described by some is the pars ascendens. ANATOMY OF THE INTESTINES 5 The pars horizontalis superior. Beginning at the stomach, as already described, it runs outward and some- what upward to the right in a horizontal direction, with a tendency to obliqueness. The position varies, of course, considerably with the movements of the stomach, becom- ing more transverse when the longitudinal fibres of that organ are contracted, and more oblique when the stomach is dilated. The position undergoes change in gastrop- tosis, whether this be partial, as when the pyloric portion alone is dislocated, or complete. This portion of the duo- denum is the widest of this section of the small intestine and is about two or three inches in length. It is some- what bottle-shaped, dilated more at its upper extremity to form the antrum duodenale. It is covered by the lobus quadratus and the right lobe of the liver. This segment is freely movable and is almost completely invested by the peritoneum. The pars verticalis (de- scending segment) runs down in front of the right kidney as far as the third lumbar vertebra. It does not descend in a straight line, but makes a gentle curve and merges almost imperceptibly into the inferior transverse portion. Joined to this latter part it gives to the duodenum the configuration of a horseshoe with the convexity looking to the right and the concavity to the left. In the con- cavity is received the head of the pancreas. On the inner surface of the vertical segment just below its middle is the orifice of the ductus communis choledochus, and just a little above this the separate orifice for the duct of the pancreas. It is covered by peritoneum on its anterior surface only. The pars horizontalis inferior, the longest and narrowest part of the duodenum, passes over trans- 6 CONSTIPATION IN ADULTS versely from the right side to the left and at the left border of the spinal column ends in the jejunum. That which by some is described as a fourth change in direc- tion, or fourth segment, is the ascent made by the terminal extremity of the duodenum from the third to the second lumbar vertebra, at which point the jejunum may be said to begin. It has a partial investment of peritoneum on its anterior surface. It is covered in front by the transverse mesocolon and crossed by the superior mesenteric vessels ; it lies upon the aorta, vena cava, and the crura of the diaphragm. Above it is the lower border of the pancreas. Jejunum and Ileum. — The jejunum is two-fifths of the residue of the small intestine. It begins at the point already described, descends, makes numerous convolu- tions, and merges into the ileum. The ileum is the residue of the small intestine, and is the narrowest portion of it. The gyri or ansae, which these two segments form, are very numerous, and they lie closely packed together. They are arranged in a very irregular form, from left to right. Leaving the duodenum, they fill the contiguous left epigastric and umbilical regions, then the left hypochondriac and left lumbar regions, descend into the pelvis, reascend into the left iliac, pass over the hypogastric into the lower umbilical, right hypochondriac, and right lumbar regions. The ileum terminates here in that portion of the large bowel known as the csecum. This terminal extremity is rather funnel- shaped, the wide portion of the funnel directed toward the ileum. By means of the mesentery, which is a fold from the ANATOMY OF THE INTESTINES peritoneum, and which with its two layers, the ascending and descending, forms the peritoneal covering of these two segments of the small intestine, they are hung up, as it were, on the spinal column. The capacity of the small intestine is equal to six litres (about twelve pints). The Large Bowel. — The large bowel, intes- tinum crassum sen am- plnm, is about five feet in length, with occa- sional variations as in „ Showing C^cum and Funnel-shaped Tek- the Case of the small minal Extremity of the Ileum. {Sappey.) intestine. It begins at x> Line of division of the small intestine; • , . 2, Opening of the small intestine into the large the termination of the bowel ; 3, Lower section of ileo-csecal valve ; . , -, , , 4, Upper section of ileo-csecal valve ; 5, Bundles Ileum and. ends at tUe 0f muscle-fibre passing over from the small on flnn« T+ i« lnrrm«f af to the large bowel ; 6, Lower section of csecum ; <M1US. IT, IS largest at 7_ Appendix vermiformis; 8, Posterior outer the C£6CUm and STadll- *lXn*3, '< '> Posterior inner taenia ; 10, Anterior ° taenia ; 11, Haustra (Sacculi). ally diminishes in cali- bre until the rectum is reached, where there is again an increase in size. The large bowel in its course describes an arch in the concavity of which the loops of the small intestine are located. From the right iliac fossa, the point of beginning, it runs upward through the right lumbar and right hypochondriac regions to the under •surface of the liver, where it makes a curve, which is covered by the overlying liver ; passes then trans- J— i... M~-Z HT ■ESKV . HPr ' The Large Bowel in Position, (flaritnann.) a, Ascending colon ; 6, Transverse colon ; c, Sigmoid flexure ; d, e, g, Mesocolon and mesentery; h. Fascia covering inner pelvic muscles. 1, Central tendon (of dia- phragm) ; 2, Opening for the oesophagus ; 3, Bundles of muscle-fibre of the under surface of the diaphragm ; 4, Appendix vermiformis. ANATOMY OF THE INTESTINES 9 versely, with a somewhat upward tendency, onward be- tween the borders of the epigastric and umbilical regions into the left hypochondriac region, — near the spleen, about two vertebra higher than to the right, — where it again makes a curve and descends through the left lum- bar region and left iliac fossa, where it makes a sort of fold known as the sigmoid flexure ; it then passes down- ward and terminates at the anus. The large bowel is divided into various parts : the ccecum and appendix vermi- formis, the ascending colon, the transverse colon, the descend- ing colon, the sigmoid flexure, the rectum, and the anus. The csecum (blind pouch) is the largest segment of this section of the intestinal tract. It measures about two and a half inches both in its vertical and transverse diame- ters. It lies in the right iliac fossa on the right internal iliac muscle, with its end about the middle of Poupart's ligament. It is retained in position by the peritoneum,, which passes over its anterior surface and sides, and posteriorly it is connected by loose areolar tissue with the iliac fossa. Occasionally it is almost surrounded with peritoneum, which then forms a mesocsecum. About the junction of the caecum and the ascending colon the ileum opens into the large bowel by a narrow, elongated, slit-like, aperture at right angles to the axis of the bowel. The mucous membrane forms here two semilunar valvular folds which project into the bowel and constitute the ileo-cascal valve, the valvula Bauhini. At each end of the orifice the valves coalesce, and are continued as a narrow membranous ridge around the canal of the bowel for a little way, forming the frsena or retinacula of the valve. At the left extremity of the 10 CONSTIPATION IN ADULTS slit the aperture is rounded ; at the right end it is narrow and pointed. When the caecum is distended, the borders of the valvular folds are closely approximated and any reflux prevented. At the lower and posterior portion of the caecum, there is found attached a small worm-like process, the appendix ileo -Cone Poio Orifice of Appendix Vermiformis (From Harrison Allen's Human Anatomy.) vermiformis. It is from three to six inches in length ; exceptionally it may be found longer ; thus Luschka saw one that had a length of twenty-three centimetres (about eighteen inches). Its diameter is about the size of a goose- quill. It opens into the caecum by a minute orifice at which an incomplete valve-like projection of the mucous membrane is sometimes found. The Ascending Colon: that part of the large intestine ANATOMY OF THE INTESTINES H lying on the right side of the abdomen between the crest of the ilium and the diaphragm. Continuous with the caecum and smaller than it, it mounts upward and some- what outward, to the right hypochondrium, passing in front of the lower half of the right kidney. Here it makes a turn, the flexura coli dextra seu hepatica, runs horizontally and to the left, and terminates in the trans- verse colon. The right colic flexure is in contact with the lower border of the right lobe of the liver and partly also with the gall bladder. The ascending colon is covered anteriorly and on its sides with peritoneum and sometimes is completely invested by it, so that a narrow mesocolon is formed ; posteriorly it is usually covered by loose areolar tissue which connects it with the quadratus lumborum muscle and the kidney. It is thus retained in position. The Transverse Colon : the longest part of the large bowel passes transversely across the abdomen between the lower boundary of the epigastric and the upper boundary of the umbilical region to the left hypochon- drium, where it makes a turn, the flexura coli sinistra seu linealis, and passes downward to terminate in the de- scending colon. In its passage across the abdomen it describes somewhat of an arch, the concavity being directed backward toward the vertebral column. This is known as the transverse arch of the colon. This is the most movable part of the colon; it is almost completely invested with peritoneum and is attached to the vertebral column by a large and wide duplicature of this membrane, the transverse mesocolon. 12 CONSTIPATION IN ADULTS It is in relation by its upper surface with the lower border of the right lobe of the liver, with the gall bladder, with the greater curvature of the stomach, and with the lower border of the spleen ; by its under surface with the small intestines; by its anterior surface with the great omentum and the other constituent parts of the abdominal parietes. The Descending Colon passes downward through the left hypochondrium and the left lumbar region to the upper part of the left iliac fossa where it enters into the sigmoid flexure. The Sigmoid Flexure. — This is normally the narrowest portion of the large bowel and lies in the left iliac fossa. As usually described, the gut makes a double turn upon itself; begin- ning at the termination of the descending colon it curves upward, then descends and t, again makes an upward curve, the whole having the shape of the figure " § " — whence the name — and terminates in the rectum. According to Treves, however, this description, though classic, is erroneous; the flexure does not resemble the " § " Roma- num ; it has rather the figure of an omega — "ft." He describes it as follows : " The descending colon ends just at the outer border of the psoas. The gut here suddenly changes its direction ; it crosses the muscle at right angles and about (From Treves' Anatomy of the Intestinal Canal, etc.) C, Usual shape of the un- folded loop (adult) ; M, Ter- mination of descending colon; N, at the point of ending of the mesorectum. ANATOMY OF THE INTESTINES 13 midway between the lumbosacral eminence and Poupart's ligament. It now descends vertically along the left pelvic wall and may at once reach the pelvic floor. It then passes more or less horizontally and transversely across the pelvis from left to right and commonly comes into con- tact with the right pelvic wall. At this point it is bent upon itself, and, passing once more to the left, reaches the middle line and descends to the anus." Treves includes in his description of the flexure what is usually denominated the first segment of the rectum. The aver- A, Most usual arrangement of the loop when in situ. B, Rarer form of arrangement. age length of this portion of the bowel in the adult is about 17i inches. It is kept in place by a fold of peri- toneum,— the sigmoid mesocolon. The fold, however, is ample and permits of extensive movement on the part of this segment of the large bowel. The Rectum. — This is the terminal portion of the large boweh It is narrower at its upper part than the sigmoid flexure, but dilates as it descends and, just before the anus, forms an ampulla, which may reach great size. The rectum, which varies in length from six to eight inches, is usually divided into three parts, — the upper, 14 CONSTIPATION IN ADULTS the middle, and the lower portion. (As already stated, Treves recognizes but two segments, counting the first as part of the sigmoid flexure.) It begins at the left sacro- iliac symphysis, passes obliquely downward from left to right to the middle of the sacrum, making a gentle curve to the right. It regains the middle at this point and de- scends to the lower part of the sacrum and coccyx ; near the extremity of the latter bone it inclines backward to terminate at the anus, a buttonhole orifice, situated a little in front of the coccyx. The upper part of the rectum is completely surrounded by peritoneum and connected with the sacrum behind by a fold of this mem- brane, which is known as the mesorectum. In front it is separated, in the male from the posterior surface of the bladder, and in the female from the posterior surface of the uterus and its appendages, by some convolutions of the small intestines. The middle portion is closely con- nected with the sacrum ; it is covered by peritoneum on its upper and anterior portions only. The Sphincters of the Anus. The external sphincter. — Like all sphincters, its purpose is to keep an orifice, that of the anus, closed. It consists of planes of muscular fibre which surround the anus. It is elliptical in shape and intimately adherent to the integument about the margin of the anus. It arises from the tip of the coccyx, and is inserted into the tendinous centre of the perineum, merging with the transverse perinei muscle. It has both voluntary and involuntary muscular fibres. The internal sphincter is a plane of involuntary muscular fibres about one-half an inch in length, which ANATOMY OF THE INTESTINES surrounds the lower part of the rectum about above the margin of the anus. A third sphincter does not exist.1 an 15 inch The External Sphincter of the Anus (and the Perineal Muscles in the Adult Male). (Hartmann.) 1, The glutaeus maxiraus; 2, Same, divided; 3, Deeper fasciculi of the same; 4, Levator ani ; 5, 6, 7, Transversus perinei ; 8, Ischio-cavernosus ; 9, Bulbo-caverno- sus ; 10, External sphincter of the anus, a, Sacrum covered by its connective tissue ; 6, Fascia ; c, Point of origin of the muscles of the thigh. *, The latter shown to the right covered with fascia, x, Ligam. anococcygeum. Certain points in the structure of the large intestine are deserving of consideration. It strikes the eye of the beholder at once that the 1 See Kelsey, Diseases of the Rectum and Anus. 16 CONSTIPATION IN ADULTS large bowel does not present the smooth, even surfaces noted in the small intestine, but has a sacculated ap- pearance. This is due to the arrangement of the longitudinal muscular fibres in three large bands, from the beginning of the caecum at the appendix vermi- formis to the rectum. One of these bands, or taeniae, is posterior along the attached border of the bowel ; the anterior, the largest, is on the forward surface of the ascending and descending colon and sigmoid flexure, and on the under surface of the arch of the colon. The third, or inferior lateral band, is found on the inner surface of the descending and ascending colon, and on the under surface of the transverse section. These bands, being shorter than the rest of the intestine, draw it together, and so produce the appearance described. When they are dissected off, the bowel can be drawn out and its sacculation disappears. The mucous membrane, which is quite smooth and without villi, is thrown into crescentic folds, Plicce Sigmoidece, which project forward like valves between the sacculi. Their arrangement is such that their free borders are not all in the same direction.1 The rectum is not sacculated, but smooth and cylin- drical, the taeniae being wanting here. The mucous membrane of the rectum is thicker, more vascular, of darker color, and but loosely connected with the muscular coat. When the rectum is collapsed, its mucous mem- brane is thrown into folds which are in apposition with each other, and obliterate, as it were, the lumen of the bowel. When the rectum is distended, the folds disappear. 1 See chapter " Physiology of Peristalsis." ANATOMY OF THE INTESTINES 17 Houston described as valves of the rectum folds of the mucous membrane found protruding into it, and ascribed to them the function of holding up the faeces, i.e. preventing its constant descent, and consequently •constant irritation of the sphincter. They were said to be present in all persons, but to vary in number and location. It has, however, been disputed, and the weight of authority is against their existence, as a rule. This much, however, is positive, that even where such pro- truding folds do exist they have no valvular function; the rectum has no need of valves. Occasionally a large fold of mucous membrane is found, extending into the lumen of the tube ; Kohlrausch described such a fold, which he calls plica transversalis recti, and it has been seen by others. About the level of the internal sphincter five or six little semilunar valves are noted, with their con- cavities directed upward toward the colon.1 They form an irregular line around the canal. They are thus described by Dr. Horner : " The mucous coat of the rectum is thick, red, and fungous, and abounds in mu- cous lacunae and glands. It is laid smoothly above, and below it is thrown into superficial longitudinal folds called columns. At the lower end of the wrinkles between the columns are small pouches from two to four lines in depth, the orifices of which point upward ; they are occasionally the seat of disease, and produce, when they are enlarged, a painful itching."2 1 Handy, W. R., Textbook of Human Anatomy, Philadelphia, 1854. 2 Special Anatomy and Histology. Eighth Edition, Vol. II. Phila. 1857. Bodenhammer, "Observations on the Normal Sacculi of the Anal Canal," etc., Medical Record, May 26, 1888. 18 CONSTIPATION IN ADULTS The function of these little pouches, Sacculi Horneri, is apparently to collect mucus which may be required to lubricate the moving faeces, and thus facilitate its expulsion. (From Handy, Text-book of Human Anatomy.) Represents a section of the anus and rectum, showing the rectal pouches. aa, Columns of the rectum ; 66, Rudiments of columns ; c, Internal sphincter divided ; d, External sphincter divided ; ee, Folds of skin on the nates; /, Pouches; g, Bristles in the pouches. Arteries. I. Pancreatico-Duodenalis, branch of the gastro- duodenalis, branch of the hepatic, branch of the coeliac axis, supplies the first part of the duo- denum. II. Superior Mesenteric Artery : a large vessel aris- ing from the abdominal aorta a little below the coeliac axis. It passes forward between the pan- creas and transverse portion of the duodenum and descends between the layers of the mesentery to the right iliac fossa, where it terminates, con- siderably diminished in size. It supplies the ANATOMY OF THE INTESTINES 19 whole length of the small intestine except the first part of the duodenum. It also supplies the caecum, ascending and transverse colon. Branches: Vasa intestini tenuis, fifteen or twenty branches, arising from the convex side of the artery. They anastomose with each other in a series of arches which become smaller and more numerous as they approach the small in- testines, to which they are finally distributed. Inferior pancreatico-duodenal is distributed to the transverse and descending portion of the duo- denum ; it anastomoses with the pancreatico- duodenals. Ileo-colic, distributed to the lower portion of the ileum, caecum, and vermiform appendix. Anas- tomoses with branches from the inferior mesen- teric artery. Coliea dextra to the ascending colon. Colica media to the transverse colon. The artery is accompanied in its course by the superior mesenteric vein, and is surrounded by the superior mesenteric plexus of the sympathetic nervous system. III. Inpeeior Mesenteric Artery arises from the left side of the abdominal aorta just before the point of bifurcation. It is not so large a vessel as the superior mesenteric artery. It supplies the descending colon, the sigmoid flexure, and the greater part of the rectum. Branches : Colica sinistra to the descending colon. Arteria sigmoidea to the sigmoid flexure. 20 CONSTIPATION IN ADULTS IV. Hemorrhoidals Superior is the continuation of the inferior mesenteric artery from the iliac fossa downward. It descends between the meso- rectum to the rectum, and at about its mid- dle divides into two branches which descend on either side of the rectum, where they divide into several smaller branches, which are dis- tributed to the muscular and mucous coat of this section of the bowel near its lower end. These anastomose with each other, with the middle hsemorrhoidal and inferior haemorrhoidal arteries, and with branches from the internal iliac and internal pudic arteries. This artery is accompanied by the inferior mesenteric vein, and is surrounded by the inferior mesenteric plexus of the sympathetic nervous system. V. Middle Hemorrhoidal Arteries. Branches of the internal iliac, distributed to the anterior part of the rectum. VI. External Hemorrhoidal Arteries. Two or three small arteries — branches of the internal pudic, distributed to the muscles and integu- ment about the anus. Veins. — Superior mesenteric vein, Inferior mesenteric vein, unite with others to form the portal vein. Nerves of the Intestinal Tract. — The nervous system of the intestinal tract is almost altogether part of the great sympathetic system. The nerve filaments and ANATOMY OF THE INTESTINES 21 Ret. Diagram to illustrate the Nerves of the Alimentary Canal in the Dog. Foster, Human Physiology. The figure is for the sake of simplicity made as diagrammatic as possible, and does not represent the anatomical relations. Oe to Ret. — The alimentary canal, oesophagus, stomach, small intestine, large intes- tine, rectum. L.V. Left vagus nerve ending on front of stomach, r.l. recurrent laryngeal nerve supplying upper part of oesophagus. R. V. right vagus, joining left vagus in oesophageal plexus, oe. pi., supplying the posterior part of stomach and con- tinued as R'. V. to join the solar plexus, here represented by a single ganglion and connected with the inferior mesenteric ganglion (or plexus) m. gl. — a. branches from the solar plexus to stomach and small intestine, and from the mesenteric ganglion to the large intestine. Spl. maj. Large splanchnic nerve arising from the thoracic ganglia and rami com municantes r.c. belonging to dorsal nerves from the 6th to the 9th (or 10th). Spl. min. Small splanchnic nerve similarly arising from 10th and 11th dorsal nerves. These both join the solar plexus and thence make their way to the alimentary canal. C.r. Nerves from the ganglia, etc., belonging to 11th and 12th dorsal and 1st and 2nd lumbar nerves, proceeding to the inferior mesenteric ganglia (or plexus) m. gl. and thence by the hypogastric nerve n. hyp. and the hypogastric plexus pi. hyp. to the circular muscles of the rectum. l.r. Nerves from the 2nd and 3rd sacral nerves, S.2, S.3 (nervi erigentes) , proceeding by the hypogastric plexus to the longitudinal muscles of the rectum. 22 CONSTIPATION IN ADULTS plexuses are derived more directly from the following plexuses, which are themselves but part of the great solar, or epigastric, plexus : The superior mesenteric plexus, The inferior mesenteric plexus, The aortic plexus, The hypogastric plexus. The superior mesenteric plexus accompanies the su- perior mesenteric artery into the mesentery, and there divides into a number of plexuses which follow the branches of the artery to the parts supplied by it ; namely, the small intestines, the cecum, the ascending and the transverse colon. The inferior mesenteric plexus (which originates more directly from the aortic plexus) accompanies the rami- fications of the inferior mesenteric artery to the parts supplied by it, — the descending colon and the sigmoid flexure. The superior hemorrhoidal plexus (which also is part of the aortic plexus) supplies with nerve filaments the upper part of the rectum. The inferior hemorrhoidal plexus, part of the hypo- gastric plexus, distributes itself over the inferior portion of the rectum and there unites with the ramifications of the superior hemorrhoidal plexus. These plexuses, after they have entered into the intestinal structure, divide into two distinct layers, which surround the intestinal tissues in every direction. The first layer is located between the longitudinal and the circular layers of muscular fibres, and constitutes the ANATOMY OF THE INTESTINES 23 plexus myentericus of Auerbach. The second layer is found between the mucous membrane and the sub- mucous tissue, and is the plexus of Meissner. These plexuses are formed by a network of fine non-medullated nerve fibres, with ganglia and ganglionic cells located at various points in the network. There are communi- cating branches between the two layers. Plexus of Auerbach, between the Two Layers or the Muscular Coat of the Intestine. (Cadiat.) The bowels have no direct connection with the cerebro- spinal system ; indirectly, however, they have such con- nection. As has been said, all the various plexuses above recounted are more or less part of the great solar plexus, and this receives the terminal extremity of the right pneumogastric nerve. Through the solar plexus the intestines are in com- munication with the various organs of the body ; for, 24 CONSTIPATION IN ADULTS besides the terminal portion of the right vagus nerver this plexus receives also the ends of the splanchnic nerves, the greater and the lesser, which are derived from the thoracic sympathetic gan- glia. Only the rectum and the anus are in direct communica- tion with the cere- brospinal system. Besides thebranches of the great sym- pathetic system al- ready named, these parts receive nerve filaments from the sacral plexus of the spinal cord. The part, however, that is most abundantly Plexus of Meissner from the Submucous Coat SUpplieClWltn nerves of the Intestine. (Cadiat.) p , n i from the cerebro- a, Cavity of tubular glands or crypts; b, one of the .. lining epithelial cells ; c, Interglandular tissue ; d, Lym- spinal System, IS the phatics. , n i • j external sphincter. 1. The inferior hcemorrhoidal nerve (usually a branch of the pudic) is distributed to the external sphincter and to the integument around the anus. 2. The posterior branch of the superficial perineal nerve passes to the back part of the ischio-rectal fossa and distributes filaments to the sphincter ani and the integu- ANATOMY OF THE INTESTINES 25 ment around the anus: these unite with the inferior hemorrhoidal nerve. Moreover, the integument around the anus with which Bulbo-cavernosus Superficial triangular ligament Ischio-cavernosus Muscles of thigh. Gluteous Maximus Tuberosity of Ischium Sacro-sciatic ligament Levator ani Sphincter ani s"Perficial transverse perinei The Male Perineum. (From Morris' Text-book of Human Anatomy.) 1, Inferior pudendal nerve ; 2, Superficial perineal nerve ; 3, Inferior hemorrhoidal nerve ; 4, Cutaneous branch of fourth sacral. the sphincter is in intimate relation, and the accessory muscles of the latter, receive filaments from various branches of the great sacral plexus, the cutaneous from 26 CONSTIPATION IN ADULTS the fourth sacral, the inferior pudendal, and the anterior branches of the superficial perineal. The bowels hang rather loosely attached to various parts in the abdominal cavity. They are supported and kept in place by the muscles and other structures form- ing the anterior and the posterior abdominal walls. Luschka. Die Bauchorgane des Menschen. Gray. Anatomy — Descriptive and Surgical. Treves. The Anatomy of the Intestinal Canal and Peritoneum. Hunterian Lectures. Klein, E. Atlas of Histology. Elements of Histology. Mathews. The Diseases of the Rectum, etc. Kelsey. Diseases of the Rectum and Anus. Houston. Dublin Hospital Reports, 1830 (Vol. V.). Kohlrausch. Anat. et Physiolog. der Beckenorgane. Leipzig, 1854. CHAPTER II FLATUS (IINEY2I2, WIND, GAS) In the course of the process of digestion in the intes- tinal tract, by reason of the breaking up of the various alimentary matters ingested and their elaboration into assimilable material, gases are developed in the stomach and in the intestines. They were primitively divided by Van Helmont 1 into two groups, — the inflammable and the non-inflammable, the gases of the large bowel consti- tuting the former, those of the stomach and the small intestines the latter group. This same subdivision was adopted by Priestley. The flatus thus formed is constituted by various gases : carbonic acid gas (C02, carbon dioxide) ; carburetted hydrogen (CH4, methane, marsh gas) ; nitrogen (N) ; hydrogen (H) ; sulphuretted hydrogen (H2S [HS2], hydro- gen sulphide). The last is found normally in the intestines only.2 There is some difference of opinion in regard to carburetted hydrogen, whether it is a normal constituent of the flatus or not.8 1 Tract, de Flatibus, 27. 2 In pathological conditions of the stomach, in dilatation with decided stagnation, it is also found in the stomach and readily recognized in the withdrawn stomach contents by the well-known test. 3 Planer, Sitzungsberichle d. Akadem. d. Wissenschaften zu Wien, Vol. XLII. Ruge, Ibid. Vol. XLIV. 734. Chemisch. Centralblatt, 1862, 347. Nowack und Brautigam, Muenchener Mediz. Wochenschr. 1890. 27 28 CONSTIPATION IN ADULTS The gases vary of course in volume, depending much upon the character of the food that is taken. Thus it is well known that the leguminous seeds, as peas and beans, give rise to a greater proportion of flatus, espe- cially of carburetted hydrogen, than do other articles of food. In addition to the gases thus developed, a certain amount of the volume of the flatus is derived from extra- neous sources ; a certain amount of air is swallowed with the food in the act of deglutition and a quantity of car- bonic acid gas (perhaps the greater part) is diffused into the intestines from the blood-vessels.1 The following table of Planer gives the volumes of the various gases as found by him in the stomach, in the small intestines, and in the large bowel: Gases, in Volume, Per Cent. co2 H. CH4 N. 0. SH2 Stomach. 20.79 6.71 75.50 38.83 27.58 38.22 0.37 Small Intestines. 16.23 4.04 79.73 32.27 35.55 31.63 0.05 Trace Large Bowel. 30.64 69.36 34.80 12.88 50.20 Trace2 Ruge3 found the flatus of the large bowel collected per anum, regard having been had to the influence of diet, constituted as follows : i Foster, Physiology. Landois and Sterling, Physiology. Charles, S. J., British Medical Journal, 1885, February, " The Sources, etc., of Carbonic Acid." 2 Loc. cit. 8 Loc. cit. Foster, Physiology. FLATUS (IINEY2I2, WIND, GAS) 29 Mixed Diet. Leguminous Diet. Meat Diet. co2 40.54 21.05 8.45 N 17.50 18.96 64.41 CH4 19.77 55.94 26.45 H 22.22 5.03 0.69 SH2 Trace only The flatus is an important factor in the proper func- tioning of the bowels ; it stimulates peristalsis, tends to keep the intestines distended, and contributes much to the looseness of the ingesta and of the faecal matter.1 Under normal conditions the flatus is removed from the intestines by reabsorption by the blood-vessels, and by discharge through the rectum. When from any reason this disposition of the flatus is interfered with, it accumulates, augments in volume, distends the belly, and not infrequently is the cause of spasmodic pains, more or less severe, therein. Its presence in larger volume is recognized by the char- acteristic tympanitic sound given forth by the abdomen upon percussion. The accumulation of flatus in habitual constipation, where it is mainly confined to the large bowel, is never so great as in the acute forms of constipation,2 where both accumulation and exaggerated formation with greater distension of volume are favored. Occasionally the flatus may itself become the cause of a constipation. When fsecal vomiting occurs, the abnormal accumu- lation and production of flatus is the chief factor thereof. 1 Nowack and Brautigam, loc. cit. 