Intestinal Stasis

"INTESTINAL STASIS 8.263; 1 9.9 2 4; 1 9.43 0; 1.33). - In abdominal surgery during recent years some of the principal advances have been due to the increased attention given to the study of chronic intestinal stasis, a term which comprises a sequence of changes which affect the entire gastro-intestinal canal. They are in the first instance mechanical in character and are due to the delay in the evacuation of the contents of the intestine. Later the accumulation of material in the large bowel leads to stagnation of the chyme in the small intestines and to its infection by organisms. These germs extend upwards through the ileum, jejunum and duodenum, and foul their contents from which the body obtains its nutrition. The material absorbed from the infected contents of the small intestine contains toxins and perhaps organisms. These may be in a quantity sufficient to escape excretion and alteration by the liver and kidneys. They are carried in the blood-stream and supply the cells of all the tissues of the body with a medium which rapidly produces degenerative changes in them. This infection of the contents of the small intestine by organisms is a matter of the most serious importance in its bearing on the health of the individual.

The Mechanical Changes in the Large Bowel in chronic intestinal stasis usually originate early in the lifetime of the individual. When the napkin of the infant is discarded, the child is educated to expel the faeces only once a day, so that the product of a whole 24 hours' digestion is collected in the distal portion of the large bowel and especially in its pelvic segment. The bulk of faecal matter in these circumstances appears to be greater than this section of the bowel can accommodate without undergoing alterations in form. Changes in the intestine and in its connexion to adjacent structure develop. These vary in character with the vitality of the subject. In one extreme of low vitality the colon elongates and dilates, and consequently loses in expulsive power. The elongation of the pelvic colon affords a serious obstacle to the evacuation of its contents. Infective processes in the mucous membrane also produce a condition of spasmodic obstruction. In the other extreme, in the more vigorous subject, lines of resistance are crystallized as bands or membranes which tend to retain the bowel in position and to oppose its distension and elongation. These bands are generally distributed along the concavity of the large bowel and reach a high state of development at certain definite points. At first they perform a useful function but later, as they contract, they obstruct the lumen of the bowel and tend to shorten life. These deviations from the normal are characteristic of two extreme types of intestinal stasis, within which all varieties and combinations exist.

A matter of great importance is that the cases included in the first group do not get cancer of the large bowel any more than they get carcinoma of the stomach and oesophagus, while those in the second group are very liable to the formation of cancer at any of the points of obstruction produced by the acquired bands or in the situation of the muscle at the junction of the pelvic colon and rectum, or about the sphincter ani. Another point is that the consistence of the contents of the large intestine varies greatly throughout its length; while in the caecum and ascending colon it is of a fluid or pasty consistence, in the descending, iliac, and pelvic portions of the colon it is usually firm and may be very hard. Therefore the physical character of the faecal matter is a matter of importance in the consideration of its effects upon and its capacity to pass through any portion of the bowel whose lumen is materially constricted. The explanation of the varying frequency of cancer in the two extreme types is obvious. To exert traumatism at the seat of constriction it is necessary that there should be sufficient thrust produced by the muscular wall of the bowel, and again the mechanical effect of that thrust varies directly with the bulk and consistence of the portion of the intestinal contents which is forced against the partly obstructed segment of bowel, and with the degree of the obstruction.

In the first group the very elongated bowel with its feeble muscular wall, with its inflamed mucous membrane and its very scanty contents, exerts but a slight effect upon the mucous membrane at the junction of elongated loops of colon, the kinking or obstruction by membranes being non-existent in these cases. Instead of developing excessive power by the hypertrophy of the muscle coat of the bowel the proximal colon gives up the struggle readily, dilates and prolapses. In the second group the bowel is not elongated, its wall is hypertrophied, the faecal contents are abundant and bulky, and the obstruction is acute and well defined. In the first group the enfeeblement of the muscle coat of the bowel resulting from the extreme degree of intestinal auto-intoxication eliminates the mechanical factor which in the case of the large bowel is responsible for the formation of cancer, but by causing degenerative changes in the breasts, uterus, ovaries and other organs, it renders them much more liable to cancer.

The ileal effluent is controlled and material is dammed back in the small intestine as the result of overloading of the caecum by its stagnating contents. The distension and dilatation of the caecum produce a twist or obstruction of the terminal ileum, or the ileum is constricted by an appendix which is anchored to the back of the mesentery, forming what is called a" controlling appendix,"or by an ileal kink due to the contraction of an acquired ligament or band. The weight of the stagnating contents of the small intestine exerts a drag upon the duodeno-jejunal junction. If, as is frequently the case, this angle is abrupt it is readily blocked, so that the passage of the contents of the duodenum into the jejunum is obstructed and dilatation and inflammatory change take place in the duodenum. The pylorus becomes spastic and the stomach dilates and hypertrophies. Inflammatory changes arise in the mucous membrane about the pylorus over the area in which the contents of the stomach are forcibly impacted and about the centre of the lesser curvature where strain is greatest. Later these infected areas are liable to become cancerous.

Toxic Changes in Chronic Intestinal Stasis

Carrel has demonstrated that the several tissues of the body can grow and live indefinitel y, provided they receive nutriment and are efficiently drained. Any interference with the drainage of effete products or with the supply of suitable nutriment causes the death of the growing tissue.

While most of the changes which take place in the tissues of the body in stasis are due to the effect of the deleterious products circulating in the blood stream, some are consequent upon the extension of infection from the duodenum along the ducts of the liver and pancreas. The latter are evidenced as inflammatory changes in the ducts and tissues of the liver; as gall-stones acting mechanically and producing obstructive symptoms, ulceration and cancer; and as changes in the pancreas which are degenerative, inflammatory and finally cancerous.

The most conspicuous consequences of the effects of intestinal auto-intoxication are: - (I) Loss of fat. - This in the woman is a factor of even greater importance than in a man, since she depends on it largely for the beauty of her curves and for the support of her viscera and especially her pelvic organs. (2) Changes in the skin. - The skin is stained, especially about the eye-lids, side of the neck, axillae, groins, and about the labia and thighs. This staining is accentuated in areas exposed to friction. The skin becomes wrinkled. Hairs appear on the cheek, upper lip and chin, also over the externs or surfaces of the fore-arm and the legs. The perspiration is pungent and offensive. The breasts become nobbly in their upper and outer segments, cysts are formed later and spread through the whole breast, cancer develops readily in these degenerated organs. (3) The circulation is very defective, so that the extremities and ears are cold even in moderately warm weather. The temperature of the body is always subnormal. The heart undergoes many changes due to degeneration of its muscle. The walls of the arteries become atheroinatous, impairing the circulation of the blood through the tissues. The changes in the coronary arteries produce the condition called angina pectoris, while the inelasticity and fragility of the cerebral vessels render them liable to rupture in the soft tissues of the brain. (4) The wasting of the muscles which occurs early in stasis is responsible for a great variety of symptoms. It affects both the voluntary and the involuntary muscles. Perhaps the earliest evidence of loss of power in the voluntary muscles is afforded by the loss of thoracic respiration, the patient depending for the oxygenation of the blood upon the more reflex and less exacting action of the diaphragm and abdominal muscles. The attitude of rest which is assumed in consequence is very disfiguring. It is interesting to note that this condition of abdominal respiration precedes, and is responsible for, the development of the deformities which are due to the fixation and later the exaggeration of" resting postures,"which are thus indirectly due to the auto-intoxication of chronic intestinal stasis. <<" "<< They are dorsal excurvation," flat-foot,"lateral curvature," and "knock-knee." (5) The muscle of the intestine with its ganglia and mucous membrane degenerate and their function becomes still more defective. (6) The uterus falls back and twists or bends, forming the various flexions and versions with which the gynaecologist is so familiar. (7) The voluntary muscles waste and become soft and friable. They tear easily when operated on.

Changes in the Nervous System and in the Eyes

The effect of autointoxication upon the brain and nervous system is very striking. Headache, varying in intensity, is a common symptom. Neuralgias are frequent and may involve a great variety of nerves. They may be very intense. Rheumatic pains are constantly complained of. The patient, while sleeping badly, may find it difficult to keep awake during the day. On awakening in the morning the feeling experienced may be that of extreme exhaustion, no benefit having been derived from the night's rest. The most distressing symptom of intestinal auto-intoxication is the mental depression which so frequently accompanies it. It varies in severity from a feeling of incapacity to one which not infrequently leads the sufferer to attempt to terminate an existence which has become intolerable. All efforts at mental concentration are futile, while any physical exertion is followed by a period of complete exhaustion. These patients become introspective, and women especially are liable to become intensely religious.

The term neurasthenia is very often applied to this condition of the nervous system. In some degree it is an almost invariable symptom of stasis. The patient loses control, and fits of irritability or of violent passion are not infrequent. Such a person is difficult to live with. Many are supposed to be stupid, dull, inattentive or even imbecile. This feature is more marked in the growing child, who is often at the bottom of the class and may be severely criticized or punished in consequence.

The eyes are alwa y s affected. They afford an excellent and very delicate indication of the degree of auto-intoxication and the changes they undergo are of great value to the observer.

Changes in the Kidneys

The eliminating organ on which, after the liver, most stress is thrown is the kidney. Upon it devolves the strain of getting rid of abnormal toxins and organisms, together with an excessive amount of by-products. The changes which the kidney may undergo are most variable, some being slow and almost imperceptible in their progress, while others are very acute. They include the types of Bright's disease, which probably vary with the nature of the organisms infecting the chyme. The kidney eliminates organisms, such as bacilli coli and others, into the urinary tract, through which they may be discharged painlessly and without affording any evidence of their presence.

The removal of fat results in the prolapse of the viscera, and especially of those that are dependent on it for support. The kidneys drop and their functions are impaired in consequence. The outflow of urine is obstructed by the angulation of the ureter at its junction with the pelvis or over a vessel, and hydronephrotic conditions result. The venous flow from the kidney is similarly obstructed, and in consequence the organ becomes gorged with blood and very sensitive. As it lies upon the hard floor formed by the iliac fossa its sensitiveness is increased by every movement, and the pain and distress which ensue are considerable.

Changes in the Thyroid and Ductless Glands

In stasis the thyroid becomes enlarged at the onset, and later may shrink so much that it cannot be felt by the fingers. It would seem reasonable to argue by analogy from the effect of stasis on the thyroid that the pituitary and adrenal glands behave in a similar manner in their attempt to meet the damage to structure and the drain upon their function that must result from the supply to their cells of blood heavily contaminated with toxic matter. In the case of the adrenal this is supported by the remarkable pigmentation of the skin which develops in stasis, especially in those of the brunette type.

The Importance of Intestinal Auto-intoxication in the Aetiology of Other Diseases

The depreciation in the vitality of the tissues renders them liable to be invaded and occupied by organisms which would not be able to obtain a foothold except for the lowered resisting power which results from stasis.

In young life the lymphatic tissues of the naso-pharynx are those most susceptible to infection. Later in life the gums about the teeth are constantly exposed to invasion by organisms which probably grow in the food which collects in this situation. This infection is described as pyorrhoea. When it is advanced its products infect the circulation, while the purulent material being swallowed increases the putrefactive and other changes in the gastro-intestinal tract.

Diseases which ensue on account of the lowered vitality of the tissues are: Tubercle, rheumatoid arthritis, Still's disease, Addison's disease, Raynaud's disease, diabetes, exophthalmic goitre, adenoma of the thyroid, ulcerative colitis, microbic cyanosis, asthma, dementia precox, paralysis agitans, disseminated sclerosis, infective endocarditis, and many skin diseases.

This list of diseases might be added to largely, but the number is sufficient to illustrate the view that they are due to infection of the tissues of a toxic subject by organisms or other deleterious matter which could not obtain a foothold in one whose drainage system is efficient. (W. A. LA.)

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