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Maps, plates, charts, etc., may be filmed at different reduction ratioa. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: Les cartes, planches, tableaux, etc., peuvent Atre filmte A dee taux de rMuction difftrents. Lorsque le document est trop grand pour Atre reproduit en un seul clichA, 11 est film* A partir de Tangle supArieur gauche, de gauche h droite, et de haut en bas, en prenant le nombre d'images nteessaire. Les diagrammes suivants illustrent la m^thode. 1 2 3 1 2 3 4 5 6 h V t } c ON SO-CALLED IDIOPATHIC DILATATION OF THE LARGE ! INTESTINE.' , C. F. Martin, P.A., M.D. Lecturer on Pathology, McGill University ; Assistant Physician, Royal Victoria Hospital, Montreal. Medical literature of the past three years '.ontains a few remarkable cases of unexplained dilatation of the colon and sigmoid flexure, which are of unusual interest to the pathologist and clinician. The condition has, without a single exception, proved fatal, baffling the skill of physician and surgeon alike, and yet the failure of methods ■•« V% if. :* i 1; hitherto employed, has stimulated suggestions in regard to treatment which may in future cases be of some benefit. A similar instance of the kind, which occurred a few months ago in the Royal Victoria Hospital, had, in addition, interesting features worthy of record in coanection with the others of its kind so i-arely seen by the clinician. Rec^d befqre the Montreal Medico-Chirurgical Society, November 20tb, 1896. It is interesting to note the marked similarity in the clinical his- tories of almost all the recorded cases. In nearly every instance there has been observed a more or less persistent constipation or other " trouble wilih the bowels" commencing within the first few days of life — necessitating the use of purgatives or enemata, which treatment is attended by varying success. Following upon this, comes either very early or within a few years, a noticeable abdominal distension — sometimes with frequent passage of flatus and progressively increas- ing constipation, resisting more and more the measures employed to evacuate the large intestines. Pain accompanies most of these cases and occasionally there are vomiting and intermittent liquid stools. Examination of the patient reveals a distended tympanitic abdomen, with occasional localised lateral dullness from impacted fasces, and vermicular movements may often be seen. As a rule there is some pain on deep pressure. In every case, moreover, a rectal examination fails to reveal evidence of stricture, organic or otherwise, and there is never any appreciable obstruction to the insertion of catheters or syringes. It is true that in a few instances the clinician has sus- pected a spasm of the rectum and anus, but the observations made were never positive on this point. There is often progressive emacia- tion, though sometimes death is very sudden and unexpected, and the autopsy reveals no satisfactory reason therefor. The suggesMori made by Peacock may, in a general way, be taken as satisfactory. " Death resulted from a disturbance of the vital powers in conse- quence of the iiiechanical injury of the intestine resulting from its extraordinary distension." The condition, moreover, is rarely asso- ciated with the usual symptoms of rachitis. While as a rule the malady is fatal at an early age, it is nevertheless not incompatible with moderate health for many years, arid cases which appear to have been congenital, have persisted for 28 years, as described by Peacock. Idiopathic dilatation of the colon may be present at birth, or appear later on in life, and in many of these latter cases the condition is regarded, though it would seem wrongly so, as congenital in nature. If a condition of dilated colon develop in adult life and the autopsy reveal no apparent cause, it is scarcely justifiable on this basis alone to regard the state as one undoubtedly congenital. Thus for example, in a case reported by Strahan, there was no disturbance of the bowels until adult life, and then within a few years a fatal issue resulted from colitis with dilatation, and no organic lesion was found to ex- plain the origin of the trouble. The patient, however, was a lunatio, and, as was to be expected, disregarded entirely the necessary pre- cautions to improve his intestinal condition, a,nd hence constipation and J irregularities were present which could readily induce the existing abnormalities. Indeed, Van der Kolk, as noted by flurd, found a slight dilatation of the coloa so common in the insane, as to associate the conditions very intimately, and the cause is doubtless that above given. The mere fact that no organic obstruction was found is nojb sufficient in itself to make one regard the condition as ccmgenital, par^^icularly when no symptoms whatever develop until the patient att ins adult life. It is of course of prime importance to distinguish between purely congenital cases and those which have been acquired at a later date^ for dilatation of the colon as a result of (or at all events following upon) koprostasis is by no means uncommon. Many instances are recorded of dilatation of the colon coming on late in life, but these are nearly all associated with some condition interfering directly with the evacuation of the bowels, and are obviously due to chronic con- stipation with or without constriction of the intestinal lumen. Such for example is the case recorded by Little and Callaway, and that above mentioned by Strahan, while in the same connection may be cited the interesting condition described by Mr. Gay, where as a result of atony of the bowel following typhoid fever, chronic constipation supervened and with it marked dilatation of the colon. So far as the congenital cases are concerned, it is not an unfrequent circumstance that antenatal stenosis or imperforate condition of the anus will lead to dilatation of the large bowel, either diffusely or in the form of diverticula. Cases of this kind may show equally well a series of symptoms and morbid anatomy resembling those seen in the apparently idiopathic congenital dilatations. Many instances are recorded, such for example, as those by Vulpian, Lacave, Dupleix and others ; but all these are quite evidently not idiopathic in the true sense of that word. (We understand by the term " idiopathic" in reality a confession of our ignorance, or at all events our inability to find the true organic lesion associated with the morbid anatomical condition present. For if " nothing is that errs from law," there must be some etiological factor to explain every case of abnormal dilatation of the colon). In endeavouring to differentiate between cases that are acquired and those which are purely congenital in nature, no small diffi- culty arises, and while some would apply the term congenital to those instances only where the intestine has never from birth acted normally, the definition, it would seem, is too restricting. Several cases for example exist in the literature where within the first few months of life this condition has arisen and the autopsy has i V'. M 1 1^ I i! N revealed no satisfactory explanation. Indeed, all gradations exist between the congenital idiopathic dilatation and that developing after several years. Dr. RoUeston, in his interesting paper on this subject (to which I am indebted for several references), differentiates between acquired and congenital cases, admitting, however, the impossibility of absolute divisions. He includes under the latter group only those where the bowels have never acted natui'ally and disten- sion appeared soon after birth, while all other cases are classed as acquired. In the statistical table, however, which is included in his article, this classification is scarcely adhered to, inasmuch as the case of Little and Callaway above mentioned, is regarded as congenital in origin, although the symptoms developed only late in adult life, and if such a case be regarded as antenatal, it would s em unjusti- fiable to exclude at least six or seven others where the condition has arisen even in earlier childhood, though perhaps not co-incident with birth. There can be no question that in the majority of these cases some mechanical hindrance to the evacuation of the large bowel is the main immediate etiological factor, and though these may frequently be antenatal, it could scarcely be regarded as associated with changes which have arisen in the earliest days of life in the embryo. The cases of idiopathic dilatation of the colon or sigmoid which occur, might perhaps be classified as follows : 1. Those in which the symptoms occur at birth, either as consti- pation alone, or combined with distension of the abdomen (Rolleston's congenital cases). Of those there are very few on record, apparently only four cases about which there can bo no doubt, viz. : those of Generisch, Osier, Hirschsprung and Peacock ; my own case is also to be herein included. 2. Those in which the symptoms develop shortly after birth {i.e., within a few months), or where it is stated that " from earliest infancy" there was one or other sign present. These cases are more numerous, and though they cannot be definitely called congenital, they so closely resemble them as to be practically identical, and are more than probably of congenital origin. These are recorded by Walker and Griffiths, Eisenhart. Hughes, Forniad, Osier, Bristowe, Gee (2 cases) and RoUeston. 3. Those developing after several years and associated with no pathological lesion. Such is Gee's, subjoined, in which the symptoms appear to have commenced only after 4 years of age. 4. Those cases which occur only in adult life, which can likewise be explained only as idiopathic (i.e., with no organic lesion to suggest a clue as to the cause). Of these, there are many cases too numerous to mention, e.g., those of Herringham and Bruce Clarke, Little and Callaway, Hadden, Lewitt and many others. The following table will explain these various cases and include a few details concerning each : M W H O o 4) I I Ph a o '*^ n o d (0 n o o ^' en a 2 S 01 a O o « Q 60 «1 dg 9-- o I en s a o "3 a •n -a i> o : fl : o- • 3 : & ■ !/l HI I 41 £ c en CC tf) a .-a : g en CO m -. S5- o it ce 55- ' b : ea :S, CO ,. • ^ C 99 V 0) >H 5.' tH :.2 a o O I « _cn a "S'S - • al-agc ■ o iS t- 0* ti o . a ft "co a o a d .2 a: a 8 (Dm ^<1 ^■t- I'- 5 :2 eS rt a) -J a >^ ^ 4:> >, C C Cr O O O 2 •r e a o 01. fl ft O-r; tn a a Ji en ft.. * s a d § S £ ■« .2 B S «^ ftS 0.2 * en Q ■a a a o >. o ■M a o 2 4) ft o % i .»j»-,^. As will be observed from the above table, the cases which have certainly arisen coincident with birth or before it are but five in number, while at least eight are recorded where the onset of the symptoms appeared so soon after birth that it is difficult to ascribe to these an origin different from the five undoubted congenital cases. In several instances the conditions ai'e so similar in all respects that one is scarcely justified in regarding them in the light of non- congenital {i. e. ac(juired) cases in contradistinction to the five instances mentioned. So far as constipation alone is concerned, it is difficult to believe that this in itself is the cause of the malady, but it is much more probable that the gas developed in the intestine would equally well induce a kinking and functional closure of the intestines, particularly when with a lax meso-colon the bowel may become twisted. The cause is obviously purely mechanical, and while numerous theories have been advanced in practice, none have proved entirely satisfac- tory as applying to every case on record. Among the most commonly cited of these are the following : 1. An unduly lax meso-colon, by means of which there arise kinks in the bowel, consequent constipation, and gradually increasing distension. 2. Immoderate or anomalous development of the tissues of the sigmoid flexure or colon. 3. Undue length of the sigmoid flexure in early infancy, combined with habitual constipation. 4. Defective innervation of the intestinal muscles. 5. Spasm of the rectum. 6. Adhesions. 7. Colitis, and hence weakened intestinal wall. 8. Contracted meso-colon at one place. Case Report. Without discussing at the present time the value of these different theories, I will now pass on to describe the case that has come under my notice, after which it will be possible to discuss which of these theories best accord with the conditions therein recognized. For the notes of the clinical history I am indebted to Dr. H. S. Shaw, senior resident surgeon. W. E., aged 3 J years, a male Canadian child, was admitted on January 3rd, 1896, to the surgical wards of the Royal Victoria Hos- pital on account of persistent constipation. The history given by the mother was briefly as follows : At birth the patient seemed to be well in all respects except that the bowels did not move for five days. A purgative was then administered with good effect. During the first part of his life, the child was constantly constipated, sometimes for as long a period as eleven day's. Thi.s necessitated the periodical adminifitration of glycerine suppositories and castor oil, which gener- ally produced the desired effect, flatus also passing frequently and freely. For the first year no enlargement of the abdomen was observed ; the child suffered no pain and was in all respects a quiet baby. At the end of the first year, however, gradual and progressive enlargement of the abdomen supervened until the child had attained the age of 3J years. From time to time the abdominal distension lessened, and flatus passed freely, but the bowels were inactive unless purgatives or injections were persisted in Pain was observed merely a few months before admission to the hospital, and was then associ- ated only with defsecation or injections. The stools presented at first large scyballous masses, and, later, semi-solid evacuations, with two intermitting attacks of diarrhoea. At the end of December, 1895, the constipation became alarming and no flatus was passed ; the distension and pain became more marked than ever before, while purgatives and enemata seemed use- less ; friction over the abdomen proved equally futile. Two days before admission, however, a large evacuation was obtained, and^ with it, a large amount of flatus was passed. , The personal history was negative. The family history was of considerable interest in one respect, namely, that one other child of the family had been observed at birth to present an unusually large abdomen, and likewise to require enemata and purgatives from time to time. This child lived but three months, with this condition unaltered, the fatal issue being brought about by en acute broncho-pneumonia No autopsy had been made. Condition on admission — The child is pale, fairly well nourished, sleeps well, and suffers but little pain, except at stool. The tongue is clean, the appetite good, and the bowels obstinately constipated. The abdomen is very greatly distended, having a girth of 68 cm., and is uniformly enlarged. From the ensiform cartilage to the pubes the measurement is 33 cm. Vermicular movements are distinctly seen over the lower half of the abdomen and apparently associated with the distended colon. This part of the bowel presents as a.n elongated prominence, running obliquely across the abdomen, and varying in position from time to time, and particularly with the vermicular movements. The movements are both spontaneous and easily excited by examination. On palpation there is marked gurgling; the : If ■■i - 1 : i A"- abdomen is soft, unrcsi.stant to the touch, and there is no tenderness. Khictuation is soinetiines elicited in the flunics, hut seems to vary j^reatly and is probal)ly associated with Huid in tiie intestines. Per- cussion yields a tympanitic note throughout, except for a modified dulness (m each side low down. The hepatic and splenic dulness are normal. On auscultation there are borborygmi heai'd, but otherwise! no abnormality. The rectum showed no signs of disease nor stricture. The urine is normal. In the chest there is no evidence of disease, beyond that induced by the pressure upon the diaphragm from below. An operation was performed by Dr. Bell on January 16th, and th® abdominal cavity opened in the median line, giving exit to a small quantity of serous fluid. The distended bowel was found to consist of sigmoid flexure, whose diameter was 9 — 10 cm. There was elsewhere no signs of collapse of the bowel or stricture, nor could any obstruc- tion be detected. The rectum was examined again, but found perfectly free, and the abdomen was therefore closed and nothing further done- The patient recovered well, and the bowels moved by means of enemata and the distension was markedly diminished, though the girth was never less than 55 cm. The condition, hov/ever, otherwise remained in statu quo, so a second operation was performed on Jan- uary 30th, and an incision made in the left inguinal region. Bougies were introduced per rectum to enjpty the large bowel, but failed to move some impacted faeces. Accordingiy large trochars were em- ployed and the bowel punctured in the abdominal cavity, and semi- solid faeces were then pushed out of the dilated sigmoid flexure, and the wound thereafter sutured in the usual manner. For five days the patient did well, but on the sixth day sj'mptoms of perforative peritonitis developed and death en.sued. The autopsy was performed 17 hours after death and the following notes from the report are abstracted concerning the conditions of the abdominal cavity : The opei'ation wounds are both almost entirely healed On open- ing the abdominal cavity fetid gas escapes, and about 400 cc. of creamy, greyish fluid having a faeoal odour is removed. It is for the most part free, but in portions is sacculated off" by the recent plastic adhesions in the peritoneum. There is a very recent general peri- tonitis ; the omentum for the most part covers the small intestines and is adherent to the lower end of the sigmoid flexure. The visible intestines are covered with a plastic exudate, and the coils are loosely adherent to each other. The lower half of the abdomen is occupied by the enormously distended and hypertrophied sigmoid flexure, which 9 lies completely across the abdominal cavity with its concave bonh.'r looking to the left. The upper half of the hwp is the wider and longer, nie»usuring 20 cm. x H cm., whih; the lower half is 15 cm. long X 5 cm. in diameter. There are fairly loose adlui.sions Ixitvveen the two portions of the loop, »is also between the end of tlie sigmoid Hiixure and the left abdominal incision. There seems to be a thickening of that part of the meso-colon which approximates the two ends of the loop and causes traction on the lower end, thus creating a partial narrowing of the lower portion. The sigmoid immediately above this narrowed part is dilated with a pouch formation on its inferior surface, evidently caused by gravitation of accumulated fajces. On the outer and lower surface of the sigmoid are a number of Lembert sutures to which the omentum is adherent. Union is com- plete, except at one median point where a small perforation, 2 mm. in diameter, indicates the evident origin of the peritonitis. On opening the sigmoid, solid fa'ces weighing .S50 grms. are removed, the wall is greatly thickened, measuring on an average 5 mm. The mucosa itself is normal without any ulceration. The rectum is of about normal size and thickness, and there is nowhere any evidence of constriction. The descending colon is also greatly thickened, somewhat I \ •■ . '(.■ ■ '■