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 enfeeble- ment 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 hyper- trophies. 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 demon- strated that the several tissues of the body can grow and live indefi- nitely, 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 cir- culating 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: (l) 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 atheromatous, 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 vol- untary 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 dia- phragm and abdominal muscles. The attitude of rest which is as- sumed 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 gynaecol- ogist 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 auto- intoxication 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-intoxicatipn is the mental depression which so frequently accom- panies 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 always 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 im- perceptible 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 es- pecially 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 hydrpnephrotic conditions result. The venous flow from the kidney is similarly obstructed, and in consequence the organ becomes gorged with blood and very sen- sitive. As it lies upon the hard floor formed by the iliac fossa its sensitiveness is increased by every movement, and the pain and dis- tress 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 con- taminated with toxic matter. In the case of the adrenal this is supported by the remarkable pigmentation of the skin which de- velops 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, demen- tia precox, paralysis agitans, disseminated sclerosis, infective en- docarditis, 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.)
INVERFORTH, ANDREW WEIR, 1ST BARON (1865- ), British ship-owner and administrator, was born at Kirkcaldy April 24 1865. He was educated at Kirkcaldy and afterwards adopted a business career, founding in 1885 the firm of Andrew Weir & Co., ship-owners and merchants, of London and Glasgow. Having made a large fortune in business, in April 1917 Mr. Weir entered Mr. Lloyd George's government as surveyor-general of supply at the War Office, and held this post until Jan. 1919, when he became Minister of Munitions and Supply. The same year he was sworn of the privy council and raised to the peerage, being also awarded the American D.S.M.
IOWA (see 14.732). The pop. of Iowa in 1920 was 2,404,021; in 1910, 2,224,771; an increase of 8-1%, as against a decrease of 0-3% in the preceding decade. In 1915 the native whites of
