This section is from the book "Diseases Of The Intestines", by Max Einhorn. Also available from Amazon: Diseases Of The Intestines A Text-Book For Practitioners And Students Of Medicine.
Intestinal colic. Neuralgia mesenterica.
Pains in the intestines.
Enteralgia is present in most organic lesions of the intestines. Enteralgia of purely neurotic origin, however, which is considered in this chapter, occurs inde-pently of any anatomical lesions of the intestinal walls.
Sometimes abnormally strong stimuli may be evolved within the intestinal canal, producing painful sensations. These stimuli may be of a mechanical, chemical, or thermal character. Thus, a conglomeration of intestinal worms, foreign bodies, gall stones, or enteroliths may produce intense colic. Sometimes hardened fecal masses press upon the sensory nerves. The intestinal lumen being temporarily occluded by these masses, gases collect above this space and increase the tension within the intestinal canal, thus giving rise to intense pain (wind colic, colica flatulans, which is quite often seen in children). Sometimes the ingestion of very coarse foods, indigestible substances, tainted foods, too cold beverages, highly fermented drinks cause enteralgia. In the gouty diathesis it may precede a gouty attack or replace it. Similar to these conditions in which the enteralgia takes its origin from toxic substances contained in the blood and irritating the intestinal nerves, is also the intestinal colic met with in chronic intoxication from lead or copper.
Aside from these forms of enteralgia due to a certain discoverable irritating factor, it may also result from a perverted state of the sensory intestinal nerves themselves. The latter group is principally found in patients affected with hysteria, or spinal troubles, although it may also be of a reflex nature due to abnormal conditions of neighboring organs, kidneys, bladder, uterus, ovaries, and liver.
The symptomatology of enteralgia presents quite a varied picture, in many instances depending upon the cause of the enteralgia. If the neuralgia mesenterica is due to an error in diet, it usually begins with gastric disturbances, belching, nausea, vomiting, and anorexia. In cases in which an accumulation of fecal matter produces the enteralgia, obstinate constipation and flatulence, occasionally alternating with diarrhoea, precede the attack. In chronic lead poisoning there are present a bluish line around the gums near the teeth, retarded pulse, and oliguria.
The principal symptom of neuralgia mesenterica is pain within the intestine. It seldom appears suddenly and with great violence. As a rule, the pains are at first of light character and gradually increase in intensity. They are of a cutting, throbbing, or pinching nature, and are experienced usually in one and the same abdominal area, most often in the region of the navel. Starting from this spot they radiate toward the back, the loins, the thighs, and the testicles. In some cases the pain wanders from one area to another and may be felt at different times in the most varied regions of the abdomen. In the latter instances the pains are accompanied by a visible peristaltic restlessness of the intestine, often producing gurgling noises.
In mild cases the pain is quite endurable, and often lasts but a short while. In severer forms of enteralgia, however, the pains may be of extreme violence, and in weak patients may produce syncope, while in the more robust they may give rise to attacks of panting and crying. The face grows pale and assumes an expression of intense suffering. The forehead is covered with cold perspiration and the extremities are cold. The entire picture resembles very much that of shock.
Pressure in many instances slightly alleviates the pain, and for this reason the patients often press their hand or some other hard substance against their abdomen. For the same reason they are often found lying on their abdomen, pressing the latter against the mattress. In cases, however, in which the intestinal tract is filled with gas and the abdomen therefore in a tense condition, even very slight pressure increases the pains. Under these circumstances a suspicion of peritonitis often arises. Ultimately the pains gradually decrease, and disappear much quicker if the accumulated fecal masses and gases have been evacuated spontaneously or by means of injections. The attack is then over:
Spastic contractions of the intestine are often encountered, especially when the pains are of intense character. If these contractions involve a large part of the intestine, as is often the case in lead colic, the abdomen appears trough-shaped. The abdominal walls are quite tense and often very rigid. In case the spasms are limited to isolated intestinal coils, the abdomen is not drawn in and at some places where there are intestinal coils overfilled with fecal matter and gas, may asymmetrically protrude. In stercoral and wind colic the abdomen usually is tympanitic.
Constipation is almost always present. Frequently there is also a retention of the intestinal gases. If the latter are passed in considerable quantity, the pains often subside for a short while, or, in some instances, especially in the so-called wind colic, entirely disappear.
The intensity and the duration of the attack are subject to great variations. It may last from a few hours to several days. The pains are sometimes but very slight, and again of such violence that even large doses of opium are hardly effective.
Aside from the above-mentioned symptoms there exist quite often shortness of breath, palpitations of the heart, a sensation of oppression, tenesmus, strangury, hiccough, vomiting, seldom pollutions and priapism. Occasionally cramps of the calves and even general convulsions are observed. In cases of hysteria hyperesthesia of the abdominal walls is encountered.
Enteralgia is easily recognized when it presents the above-described characteristic picture. Its neurotic nature, however, will be inferred from the following features: It appears in attacks, and subsides suddenly. There are almost always other nervous symptoms present. In enteralgia due to anatomical lesions of the intestine the pain is, as a rule, increased by pressure upon the abdominal walls. Another distinguishing mark for the latter is that it is more often accompanied by diarrhoea, and that the dejecta contain pathological admixtures (blood, mucus, rarely pus).
With regard to the differential diagnosis the following conditions which are accompanied by abdominal pains will have to be excluded: Rheumatic affections of the abdominal muscles, lumbar abdominal neuralgia, hyperaesthesia of the abdominal walls, peritonitis, biliary and renal colic.
Rheumatism of the abdominal muscles is characterised by the following features: The pain is situated over the superficial area and not within the abdominal cavity. It often changes its seat. It is of longer duration than enter-algia and does not show any distinct exacerbations nor diffusion. Pressure increases the pain, while rest in a recumbent position eases it. Anti-rheumatic remedies (salol, sodium salicylate, salipyrin) subdue it.
In lumbar abdominal neuralgia the pain is localized on the surface and limited to one intercostal space which is very painful to pressure. The pains often radiate to the back, the hypogastrlum, and the genital organs. Anti-neuralgic remedies (antipyrin, antifebrin, phenacetin) are often efficient.
Hyperaesthesia of the abdominal wall is, as a rule, met with in hysteria and neurasthenia. The pains are localized in the superficial layer. The slightest touch of the skin of the abdomen increases the pain. The faradic current often quickly removes it.
In peritonitis there is almost always fever, and the pain is increased on pressure. Meteorism is here much more frequently encountered than in intestinal colic. Frequently dulness in the lower part of the abdomen (exudation) is observed.
Biliary and renal colic are recognized by the situation of the pain which often corresponds to the location of the affected organ. Besides, other symptoms are usually present which are characteristic of the latter (icterus, strangury).
The prognosis of intestinal colic is almost always good with regard to life, for the attack usually ends in recovery. Exceptional cases of death have, however, been observed by Oppolzer 1 and Wertheimer.2
The treatment consists, first, in measures directed toward the removal of the cause, and secondly, toward the relief of the pain. In most cases of intestinal colic a thorough evacuation of the bowels is of benefit. For this purpose injections of a considerable quantity of water (one to two quarts) or of olive oil (one-half to one pint) are very serviceable. Mild cathartic remedies, castor-oil, calomel, and the like, may also be administered. In cases in which worms have been found a vermifuge must be given with the cathartic. If meteorism is quite pronounced massage of the abdomen may be tried. If the colic is due to an error in diet, the latter must be strictly regulated. If due to a general cold, hot beverages (tea, infusions of camomile and of peppermint), hot poultices over the abdomen are of value.
1 Oppolzer: Wiener med. Wochenschr., 1867.
2 Wertheimer: Deutsches Arch. f. klin. Medicin, 1866, Bd. 1.
In nervous enteralgia occurring in patients suffering from hysteria and neurasthenia the treatment should be directed toward the improvement of the latter conditions. Climate, electricity, massage, and hydrotherapy play a predominant part here.
The following symptomatic measures which serve to subdue the pains are of great importance: If the colicky pains are quite severe, the administration of an efficient dose of an opiate is indicated. Tincture of opium may be given in doses of fifteen or twenty drops, or opium extract, 0.03 to 0.05; or morphine, 0.01 to 0.015, may be injected subcutaneously. Even in cases in which the colic is due to a retention of fecal matter, the narcotics just mentioned are indicated, for they relieve the spastic contractions of the intestines.
During a severe attack of intestinal colic the diet should consist principally of liquids, small quantities of milk and broth being given at frequent intervals (about every two hours). If the attacks recur quite often, the application of the galvanic current (one electrode within the rectum, negative pole, the other over the abdomen) is sometimes of benefit.