Chapter XXXIX: Front Matter (39)

The integrity of intestinal digestion depends upon the normal performance of all the preceding stages of digestion. Perfect insalivation, mastication, and gastric digestion are necessary to a proper action of the intestinal juices. The first rule of treatment in the chronic form is to examine into the condition of the mouth and teeth--to insist upon a slow and thorough mastication of food, especially of starchy food. Mastication is under the control of the individual, and he refuses to exercise this salutary means of prevention and cure at his own risk. The habit of chewing on both sides should be cultivated. All habits which waste and weaken the saliva should be given up, as smoking, chewing, and needless expectoration. Where the teeth are imperfect they should be attended to; false teeth should replace absent ones. All means should be used for improving gastric digestion: complete solution of food here means easier work for the intestine, and sometimes the cure of intestinal indigestion by removal of its cause. The rules which more directly bear upon the subject of intestinal dyspepsia are these: All the causes which have acted to bring about the disease should be removed. A change from a hot climate to a cooler and dry one will sometimes have an immediate good effect. Especially is this the case if travel is combined with change of scene. The substitution of exercise for inertia, of fresh for confined air, and the abandoning of occupations and habits of dress which hinder the freedom of movement of the abdominal muscles are of the highest importance. The patient should be made to cultivate pleasure instead of work if his mind has been overtaxed in his profession or business. Relaxation of the strained energies is indispensable to recovery. This rule is as applicable to school-children as it is to the overworked adult, man or woman. The benefits of travel, with change of scene and air, cannot be overestimated. Pedestrian tours in the mountains for young men, a trip to Europe for men and women in middle life, will secure the best results. For men who work much with their brains nothing is more conducive to aiding intestinal digestion than manual labor in the garden or workshop as a recreation. Exercise on horseback is pleasurable and improves a sluggish abdominal circulation. Rowing is good for younger men if it is confined to the field of pleasure, and is not made a task. For very feeble persons, especially for women, massage serves the purpose of exercise. The Swedish movement cure expands the thorax and abdomen, hastens the circulation, and quickens all the functions of nutrition and secretion.

A course of treatment would be incomplete without suggestions as to bathing. Life at the seashore would be of little service without the daily plunge in the surf. Still salt-water bathing is better for children and {633} delicate women. The reaction should be thorough to secure the best results. It is much to be regretted that hydrotherapy is not available and is not made use of more generally. A well-managed establishment where appropriate regimen and good and sufficient food could be combined with the renewal of the tissues by bathing would be of great advantage in all forms of indigestion. Nearly all of the benefit derived from the Hot Springs of Arkansas in chronic cachectic diseases follows upon the immediate improvement of the digestion and nutrition. The Warm and Hot Springs of Virginia have an equally good effect upon torpid abdominal functions. The Russian bath, the very hot bath, the cold plunge, the cold douche to the back or abdomen, and the cold pack to the abdomen, are means which may be employed at home for inducing a revolution ending in reform in the state of the digestive organs.

Irregularity in the hours of eating is of so much injury that rules must be given to enforce uniform habits. Instead of the light breakfast and heavy dinner, a good breakfast, a midday dinner, and a light tea are to be preferred. It is of much value to regulate the appetite according to the needs of the body and to avoid excess in everything. In this disease eating too little or starvation to a moderate degree gives that rest to the intestine which is necessary to its restoration to health.

The selection of the food should not be left to the patient; the dietary should be chosen for him with a view to lessening intestinal labor. In general terms, this should consist of a moderate amount of albuminoid food of the most digestible kind, and of farinaceous food and fats in an acceptable and digestible form. In other words, as the intestine digests proteids, starch, and fats, no exclusive diet can be devised which will secure a perfect result. In each case the examination of the stools and experience with different articles of diet must be made the means for determining upon a suitable regimen.

The exclusive milk diet is the best starting-point in feeding a patient suffering from acute or chronic indigestion. In addition to the fact that milk has all the elements of a perfect food, it contains sugar and fat in the most favorable condition for absorption; the casein of milk alone requires transformation into peptone. The pancreatic juice has the greatest activity in its effect upon milk, as is easily demonstrated by the artificial digestion of milk by pancreatic extract. In milk, therefore, we find a most easily digestible and most highly nutritious food for such cases. Instead of milk with cream, skimmed milk will be found sometimes to serve better the purpose of an exclusive diet, because it has less fat and because larger quantities can be taken without distaste or a sense of repletion. Koumiss may be added to the milk diet; it is digestible, palatable, and nutritious.

The peculiar and very active diastatic ferment of pancreatic juice converts starch into sugar very readily. Farinaceous articles of diet can be added to milk with advantage. Digestion takes place more slowly and more thoroughly in consequence, and an additional article of nutriment is obtained. Thus, milk can be diluted with a thick gruel of barley or oatmeal, or some of the best of the various artificial foods can be stirred in. To the milk diet may be added animal broths or soups prepared with vegetables, animal jellies, or some of the ready-prepared beef-essences. They may not in themselves be highly nutritious, but they contain at least {634} the salts of meat, and act as stimulants to the appetite and to the secreting glands.

Such a rigid diet cannot be kept up for a very long time without change; the appetite craves variety. Therefore solid albuminoid food in small quantity may be added to milk and farinaceous diet. Sweetbread boiled in milk, without dressing of any kind, is well suited for a beginning of animal diet. Oysters for some palates make an agreeable variety without putting much strain upon the digestive powers. They should be eaten uncooked, as cooking in any way renders them less digestible, and for greater precaution the hard part, or the adductor muscle which serves to keep the two shells together, should be removed. Fish boiled or plainly cooked and eaten without sauce is very easily digested. White-fleshed fish which has but little fat incorporated with the muscle-fibre is to be preferred. The patient may have eggs uncooked or slightly boiled, but one to two daily will be as much as he can well digest. The meat of poultry and game, especially that from the wings and breast, may be given even in a very feeble state of the digestive organs. When a more solid or satisfying diet is craved the patient may have beef or mutton cooked rare. Tripe and rabbit are suitable to some cases.

Bread, one day old and made light and porous, need not be denied the patient. Toast disagrees with some. To many, well-made biscuits or crackers are agreeable.

Vegetables should be given in small quantities, as the intestine is almost solely the seat of their digestion, and excess will tax too much a function which should be allowed as much rest as possible. The green vegetables contain less starch, and are therefore to be preferred. Lettuce, cabbage, kale, spinach, and celery come under this class, but even these are to be given to patients under treatment in moderation, with the intention of pleasing the palate rather than for purposes of nutrition. Macaroni and rice are easily digested.

Fruit contains very little nitrogenous matter and much water, and therefore has but little nutritive value, but it may be given to relieve the tedium of a restricted diet of milk or broths. Grapes, oranges, figs, strawberries, blackberries, raspberries, and peaches are the most digestible. But fruit should never be given as food. Fruit-juices, especially if acid and fresh, are unobjectionable. Coffee should not be allowed; its effect upon the nervous system is sufficient objection to its use. Tea can be given diluted largely with milk; cocoa, racahout, and broma are nutrient and make pleasant drinks. Sugar need not be excluded if used sparingly, and butter and oil in moderation may be permitted.

If the stomach is not disturbed thereby, wine may be taken with food to excite appetite. But except in the case of those who have always taken it, and cannot do without it, it is better to dispense with alcohol altogether. A red wine well diluted with water is a pleasant addition to the meal. Old wine is to be preferred to new, as being softer and less alcoholic. Good pure American wine from California or Virginia will answer the purpose when reliable French wine cannot be secured.

The value of mineral waters in the treatment of indigestion is great, but without proper dietetic regimen they can accomplish but little. The good results following a visit to Saratoga, Bedford, or other watering-place are due to other causes than the waters. In combination, however, {635} with the advantages of change of scene, air, good hours, and a simple diet the mineral waters aid in bringing about a cure. They are especially useful in men who drink too little water at home, in gouty and plethoric subjects, and in states of acid stomach digestion and chronic constipation. The alkaline and saline waters are the best, the former containing a notable proportion of the carbonate or bicarbonate of sodium, potassium, or lithium--the latter having neutral salts in considerable quantity.

The articles of food to be avoided are pastry, cheese, much butter or fat, meat richly dressed or over-cooked, pork, veal, lobsters, crabs, vegetable matter in excess, very cold or very hot fluids or solids.

All of the methods so far described are designed to accelerate the circulation in the abdominal organs and in the tissues generally, to quicken the secretory and nutritive processes, and to give to the intestinal secretions the foods which they can most readily digest. In the event of such means failing to accomplish the desired end, is there any direct stimulus which can be brought to bear on the intestinal glands concerned in digestion? The pancreas being the most active and most important of these, it would be desirable to have some agent which could excite its gland-structure to greater activity. Sulphuric ether has been found to have this effect; it may be given before meals. The salivary secretion begins pancreatic digestion (the digestion of starch), and therefore its outflow should be stimulated at the same time; but thorough mastication does this usually without need of further aid.

When all plans fail to secure a thorough digestion in the intestine, and unaltered food and fat are passed, while the patient grows thinner and feebler daily, artificially-digested food may be given. The intestine is thus relieved of labor, and time is given for a restoration of activity by rest and an improved tone of all the tissues and organs. Rice, bread, baked flour, potatoes, or barley may be given in combination with malt extract, which converts starch into grape-sugar and dextrin.

As pancreatic juice acts both upon proteids and starch, an extract of the pancreas has a more general application than an extract of the stomach--pepsin. Roberts of Manchester has given full directions for the method of digesting food by pancreatic extract. Beef, milk, and the farinacea may be digested, the albuminoid substances being changed into peptones, the starchy matters into dextrin and sugar, capable of being absorbed readily with but little or no further alteration in the digestive tract.[18] Pancreatic emulsion (Dobell) is another method of giving fat emulsified.

[Footnote 18: Fresh pancreatic extract is made by cutting into small pieces the pancreas of the pig (which is the best), the ox, or sheep. The pancreas of the calf yields an extract which acts only on albuminous substances, but not on starchy matters. The divided pieces of the pancreas, well freed from fat, are put in a well-corked, wide-mouthed bottle with four times their weight of dilute alcohol (one part of rectified spirit to three parts of water). The mixture should be agitated once daily: at the end of a week the mixture is filtered through paper until it is clear. A well-made liquid extract of pancreas is made and sold by Metcalfe of Boston, and a solid extract by Fairchild Bros. & Foster of New York. No doubt improvements will be made in the processes of manufacture of these extracts, and better results will in time be obtained from their use.]

A less successful way of gaining the same object is by administering the pancreatic extract internally. The difficulty lies in conveying the extract (the ferment of which is destroyed by the acid gastric juice) through the stomach in safety. This chemical danger is thought to be obviated by giving the extract one to two hours after eating with a {636} protecting guard of an alkali, the bicarbonate of sodium; but the mechanical difficulty of securing direct transit through the stomach to the intestine early enough and in quantity enough to digest the duodenal contents is as great as the chemical obstacle. It is very doubtful whether this method of use can be of any real service.

In those cases in which the form of indigestion is due to, or is associated with, a deficient hepatic secretion--a condition indicated by offensive and light-colored stools and other symptoms--it is advisable to stimulate the liver to increased secretion. It is probable that the same remedies which excite a flow of bile do at the same time stimulate the pancreas. The best of these are euonymin, sanguinarin, iridin, ipecacuanha, colocynth, jalap, podophyllin, sodium sulphate, and potassium sulphate. Sodium benzoate, ammonium benzoate, and the salicylate of sodium are also powerful hepatic stimulants. As one of the purposes of the bile is to create the alkaline medium necessary for pancreatic digestion, the administration of an alkaline[19] solution in full doses, as in the form of mineral water, when gastric digestion is finished, may make amends for the lack of bile. A combination of an antiseptic and the alkali may to some extent supply the deficiency still better, as the bile is the antiseptic of the intestinal canal.

[Footnote 19: The waters of Ems, Vichy (Grande Ville or Hôpital Springs), Vals, or Bilin may be used for this purpose.]

Atony of the intestinal wall leads to flatulence, colics, and constipation, and would be a cause of indigestion if none other existed. It is to be treated by the general rules already given, by electrical stimulation of the abdominal muscles with the faradic current, or by the effort to stimulate the intestinal wall more effectively with the galvanic current. Strychnia in small doses should be given for some time. In women of relaxed muscular fibre with enlarged abdomens an elastic belt may be worn with advantage.

After the special aids to the parts concerned in digestion, tonics are called for to combat the general want of tone and anæmia. The saccharated iron, the carbonate, potassio-tartrate, lactate, pyrophosphate, or the ferrum redactum may be given. The syrup of the iodide of iron is the best form for children. The bitter tonics are inadvisable except for loss of appetite in cases where the stomach is not disordered. Quinia is available in a large number of cases in which malarial influence plays a part. Strychnia is a good general tonic, and may be prescribed combined with mineral acids, particularly with the dilute hydrochloric acid.

The special symptoms which call for treatment are flatulence, abdominal pains, and constipation. All the remedies already described are directed toward their relief. But sometimes they appear in so exaggerated a form as to need immediate attention. The many remedies for colic and tympanitic distension which have the property of relieving spasm and absorbing gas find application in these conditions. Constipation is not to be treated by laxatives if it can be avoided. But the bitter waters, Friedrichshall, Pullna, Hunyadi Jânos, and Rakoczy, by exciting bile outflow, are sometimes of undoubted curative value.

The form of dyspepsia called strumous, as it occurs in children of anæmic appearance with dry skin covered with minute scales, and with bad breath and light ill-smelling stools, demands a very thorough and {637} persevering treatment. The advantages of climate must be sought--seashore in summer with bathing, dry and moderately warm air in winter. Outdoor life in the sun, with active exercise, is to be had at the expense of education within-doors. Study is not good for children of this class except when health is made paramount to it. Cod-liver oil, either pure, in phosphatic emulsion, or in the pancreatic emulsion, is a necessity. Malt extract with the hypophosphites is beneficial. The food must be carefully selected, and the child educated to a varied diet, including fats. The skin should be anointed daily with cocoanut oil, olive, cottonseed oil, or cod-liver oil.

{638}

CONSTIPATION.

BY W. W. JOHNSTON, M.D.

SYNONYMS.--Costiveness, Fecal retention, Fecal accumulation, Alvine obstruction, Obstipation. _Ger._ Koprostase, Stuhlverstopfung, Hartleibigkeit, Kothstanung. _Fr._ Constipation, Paresse du ventre, Échauffement. _It._ Constipazione. Older synonyms: Constipatio vel obstipatio alvi; Alvus tarda, dura, adstricta; Tarda alvi dejectio; Obstipatio alvarina; Stypsis; Coprostasis (Good).

NATURE AND DEFINITION.--The act of defecation is almost wholly due to the working of an involuntary mechanism which may be set in play by the will, and is in part dominated by it, but which is frequently independent and uncontrolled by volition. Deep inspiration, closure of the glottis, downward pressure of the diaphragm, and contraction of the abdominal muscles are accessory, but not essential, to the expulsion of feces from the rectum. In certain persons, and occasionally in all persons, especially in diseases where the fecal mass is in a semi-fluid or fluid form, the strongest effort of the will cannot resist the expulsive contractions of the rectal muscle. The sphincter is kept in a state of tonic contraction by a nervous centre situated in the lumbar portion of the spinal cord. The fecal mass, supported by the bladder and the rectum, does not at first touch the sphincter; the rectum is usually empty; but when the column has been well driven into the rectum peristaltic action is excited in the rectal walls and the sphincter is firmly pressed upon. The lumbar sphincter centre is now inhibited, and the ring of muscle opens, the accessory and voluntary muscles contract, and the expulsive act is completed. In the well-ordered and healthy individual the rectal walls and the sphincter do not receive the maximum of irritation from pressure of the advancing column but once in twenty-four hours. The habit of having one movement in each day is, it may be believed, in accordance with the natural and physiological demand, although both the number and the hours of evacuating are fixed to a great extent by education. The habit once established, the mechanism of expulsion recurs at the same hour and entirely without the direction of the will. If the desire be resisted, it will be most apt not to return until the same hour on the next day.

Defecation depends for its normal character upon the healthy functioning of the organism, but especially upon the normal processes of digestion. The character of the rectal contents as to composition and consistence, and the time of the arrival of the mass at the sphincter, are {639} regulated by the taking of food at stated hours and by its normal digestion and absorption. Unaltered or partly-changed remains of the ingesta pass down the bowel, mingling with the secretion from the intestinal glands and with mucus and epithelium. As this mass passes into and through the colon, being propelled by regular peristaltic waves, it acquires odor from the development of a substance which is a final product of the putrefaction of albumen.[1] Gradually the more fluid elements are absorbed, and in the descending colon a less fluid or semi-solid consistence of the feces is reached. A healthy digestion and assimilation, with active and regular contractile movements of the muscular walls of the small and large intestines, are essential to normal defecation.

[Footnote 1: Ewald, _Lectures on Digestion_, New York, 1881, p. 106.]

Constipation may be defined to be that condition in which there is a prolonged retention of the feces or in which they are habitually expelled with difficulty or in insufficient quantity.[2] While there are individual peculiarities due to habit or nature, the custom with most persons of having one movement in the twenty-four hours would cause any longer retention of the rectal contents to be considered constipation. The limits between health and disease are not well defined, and a failure to evacuate the bowels for several days need not be considered pathological nor require medical interference. In persons otherwise in good health such an occurrence due to neglect, change of habit or diet, as in travelling, would cause no interruption to health or comfort. Nature brings relief sooner or later and re-establishes order and regularity. In many cases constipation is a primary disease and the cause of many secondary disturbances, but it is often the effect or the symptom of various acute and chronic diseases. It may be acute or chronic.

[Footnote 2: Cases of constipation due to mechanical obstruction from changes in the wall of the intestine or to exterior pressure will not be considered in this article.]

In long-continued constipation the intestinal contents are so retarded in their progression along the canal that they undergo a too early and too complete absorption of their fluid portion. In time there are an accumulation and impaction of dry fecal masses in the rectum, sigmoid flexure, descending transverse colon, or cæcum. An obstacle is thus created which may ultimately close the tube entirely and cause intestinal obstruction.

ETIOLOGY.--1. Constipation occurs most frequently in advanced life. It is the effect of loss of peristaltic force and of a diminution of sensibility in the lower bowel, and is associated with general functional inactivity and with muscular degeneration and obesity. Infants are more subject to constipation than children of one year and over. In many instances this is due to artificial feeding with cow's milk, condensed milk, and the patent foods so largely used, or with any diet unsuited to the digestive organs. Imperfect digestion of casein or other food, the filling of the bowel with a dry mass difficult to propel, and the consequent catarrhal state of the mucous membrane, are causes of both constipation and diarrhoea. Feeble, delicate children with imperfect muscular development, and children born rachitic, scrofulous, or syphilitic, are generally constipated.

2. Women are prone to constipation much more than men. False modesty, which imposes restraint upon young girls, and their ignorance {640} of the necessity of regularity, their habits of indoor life, and avoidance of exercise, are largely the causes of this. But the anatomical structure and physiological life of the woman offer another explanation. At every menstrual period the uterus enlarges and exercises a greater compression upon the rectum. A tender and enlarged ovary (and at the menstrual epoch the ovary is always tender and enlarged) exercises an inhibiting action upon the muscles which bring the feces in contact with it in their downward passage. In the married woman recurring pregnancies lead to the habit of constipation from the long-continued pressure upon the colon, sigmoid flexure, and rectum, from the extreme stretching of the abdominal muscles, and from the paralyzing effect of compression during labor. The relaxed condition of the pelvic and abdominal organs after labor offers no resistance to the distension of the rectum and sigmoid flexure. The cessation of the catamenia is accompanied with constipation, nervousness, and a feeling of ill-defined apprehension when the bowels are moved, or abdominal pains deter many persons, chiefly women, from habits of regularity. All uterine and ovarian derangements by mechanical or reflex means bring about the same result. Chlorosis and anæmia in girls are almost invariably associated with constipation.

3. Hereditary influence shows itself very markedly in the tendency to constipation which is seen in many members of the same family. This is probably more often apparent than real, and is the result of neglect of the proper attention to the wants of children and of the perpetuation of vicious habits of taking purgatives.

4. The habits of life and the occupation of the individual have much to do with the causation of constipation. Those who lead active outdoor lives are generally regular in their daily movements, but persons of sedentary pursuits or who work in constrained attitudes--lawyers, clerks, tailors, shoemakers, and seamstresses--are predisposed to constipation. Intellectual work, not only from the muscular inactivity which it entails, but from the diversion of energy to the nerve-centres, develops the constipated habit as well as indigestion. Men who are overworked in business, employés in banks, government offices, shops, etc., bring on the habit from the hurry incident to their occupations. Luxurious and enervating habits of life, over-eating and sloth, with the over-indulgence in alcohol and tobacco, have the same effect. All the influences which deteriorate health, such as bad ventilation and over-heating of rooms, foul air, want of cleanliness of the person, indigestible food, imperfect mastication, tight-lacing in women, compression of the abdominal organs in men, can be said to share in bringing it about. Servants, especially women, are constipated more frequently than their masters. This is due to ignorance and neglect, and sometimes to excessive tea-drinking and irregularity in eating.

5. Neglect to establish or continue a habit of daily regularity in defecation leads to the accumulation in the rectum of masses of feces. Resisting the desire to empty the bowel interrupts the necessary reflex acts, and finally the muscular excitability and response to the presence of feces are entirely wanting. The continued contact of fecal matter with the mucous membrane wears out its susceptibility; the over-distension of the rectum enfeebles the power of its muscular wall, as is the case when all hollow muscular organs--stomach, heart, bladder--are overstretched. Thus a {641} neglect to answer the demand for a daily movement and the failure to completely empty the rectum will gradually develop constipation in a person who has before been perfectly well regulated. In childhood failure to teach and to insist upon good habits is the cause of much of the trouble of after-life.

6. Acute and chronic diseases of the brain and spinal cord bring about constipation. Meningitis, encephalitis, and myelitis, senile dementia and softening, have it as a symptom at some time or other. In encephalitis and myelitis there is an interruption of motor nerve-currents. In meningitis and tetanus the muscular walls of the bowel and the abdominal muscles are in a state of tonic contraction.

7. The use of aperients is an important agent in developing the constipated habit by over-stimulating and wearing out muscular activity. The idea that a daily movement is a necessity, and that an occasional purgative is useful in relieving the system of morbid matter which would otherwise induce disease, is the chief source of this hurtful custom. The traditional meaning attached to the term biliousness implied the resort to cathartics for its relief, and it is much to be regretted that with our more advanced knowledge the effort should be made to revive the use of this term, which was wellnigh abandoned. More ignorance and erroneous treatment has hung upon the theory of biliousness than upon any other doctrine of medicine within the past thirty years: it is well for physicians to condemn it and to resist its reintroduction into scientific phraseology.[3] If the term bilious as applied to diseases were abandoned, much good would come of it. The general use of purgative mineral waters has added to this evil. Among the better classes these waters play the same part as the liver regulators and vegetable pills do among laborers and servant-maids. Both gratify the innate love for self-medication by a resort to cathartics for the slightest ailment. At first the injurious effects are not apparent, but in time the reflex function is not brought into activity except by artificial aids. The intestinal and rectal muscles must be whipped into action, their normal contractile power being lost.

[Footnote 3: For an excellent and dispassionate statement of the reasons for abandoning the theory of the influences of bile as a cause of disease, and the use of the term bilious, consult _The Bile, Jaundice, and Bilious Diseases_, by J. Wickham Legg, chaps. viii. and xxix. The Hippocratic and Galenical belief has been transmitted with but little alteration through Stoll, Andrie, Abernethy, and Copland to the writers of to-day on biliousness.]

8. Certain vegetable and mineral substances taken either intentionally or by accident constipate the bowels. Chief among these stand opium and its preparations. All opium-eaters are constipated. Lead which is accidentally taken into the system by workers in metals, painters, etc. invariably produces obstinate constipation. The use of tobacco in excess has the effect of deranging digestion and causing constipation in many persons, but this result is occasional only.

9. Chronic diseases of the lungs and heart, by enfeebling the muscular movements which take part in defecation, as well as by the general feebleness and the chronic intestinal catarrh and indigestion which they create, are causes of constipation. Chronic diseases of the liver, especially cirrhosis, are also causes. Constipation accompanies obesity, for in very fat persons the abdominal walls have but little power of contraction; the {642} muscle-layer is thin and flaccid. There is also in such persons in advanced life an accumulation of fat in the mesentery and around the colon. The muscle of the bowel is in a state of fatty degeneration, and atony and dilatation of the gut follow.

10. Painful affections about the rectum and anus deter persons from yielding to the desire for defecation. Fissure of the anus is the principal one of these, but fistula, hemorrhoids, and local eczema have a similar influence. A simple rigidity or spasmodic stricture of the anal sphincter creates constipation.[4]

[Footnote 4: Kunemann, _De la Constipation compliqués de Contraction du Sphincter anal, et de son Traitement par la Dilatation de l'Anus_, Paris, 1851.]

11. Constipation is a symptom in chronic cachexiæ and wasting diseases, in the convalescence of acute exhausting illness, as typhoid fever and pneumonia, or in persons bedridden from any cause. Defective nutrition and degeneration of the muscle-fibre of the intestine explain these cases. In some of them, with improved nutrition, regeneration takes place with a return of contractility.

12. Disorders of the digestive system have constipation as a consequence and a symptom. The reflex sympathy between the movements of the stomach and of the intestines brings this about in gastric diseases.[5] It occurs in gastric cancer and ulcer, in acute and chronic gastritis, in dilatation of the stomach, and in pyloric stricture. The small amount of ingesta entering the duodenum in these diseases diminishes the bulk of fecal matter. In acute intestinal catarrh diarrhoea is the rule, but the bowels may be constipated in intense inflammation and ulceration of the mucous membrane, as is often the case in typhoid fever. In chronic intestinal catarrh constipation is more common in the mild forms than diarrhoea. The thickening and irritation of the mucous membrane lead to a diminution of reflex excitability and loss of elasticity and contractility in the muscular coat. Hence, except in cases where the inflammation is low down or where ulcers have formed, constipation is a more frequent symptom than diarrhoea. The alteration in the quantity and character of the intestinal secretions in chronic catarrh is stated to be an important element. This is to some extent true. Mucus, which is the chief product of this condition, leads to indigestion and fermentation of the intestinal contents and to increased irritation of the mucous membrane. The evolved gas distends the bowel and weakens its contractile power. The fecal mass when it reaches the rectum has an excess of mucus within it or around it which makes its expulsion more difficult. But the diminution or absence of bile does not constipate. In simple jaundice diarrhoea is not uncommon, and an excess of bile does not of necessity cause diarrhoea.[6]

[Footnote 5: Leube, in _Ziemssen's Cyclopædia_, vol. vii. p. 211.]

[Footnote 6: Legg, _op. cit._, p. 271.]

The effects of the modifications of the pancreatic secretion are not well known. Pancreatitis is attended by constipation. Fatty diarrhoea is believed to follow occlusion of the pancreatic duct by pancreatic calculi and chronic catarrh of the duct. Peristalsis is lost in peritonitis from the muscular coat being infiltrated with serum and paralyzed, but tuberculous peritonitis is frequently accompanied by diarrhoea.

13. Loss of fluids by abundant perspiration, by diuresis, diabetes and lactation, increases the dryness of the bowel contents and hinders free {643} evacuations. This is observed as a result of the arrival in a tropical climate and in very hot weather in any climate. The profuse sweats accompanying phthisis, acute rheumatism, intermittent fever, and unusual exercise cause constipation. Another explanation which applies to this has been offered by Good and Eberle, who ascribe constipation to the excessive action of the absorbents in the small intestine, by which the fluid portion is too rapidly and too thoroughly removed.[7] Exercise by promoting activity of the functions in general may induce constipation in this way. In spermatorrhoea the stools are infrequent. An insufficient amount of water taken with food is another cause.

[Footnote 7: Dick, _Braithwaite's Retrospect_, xvii. p. 152.]

14. Food which has but little waste to be got rid of--as milk or beef--leaves a small residuum to be propelled along the intestine, and therefore in one sense is constipating. Insufficient food acts in the same way. An indigestible diet in excess, especially vegetable food, a large part of which is insoluble, constipates by filling the bowel with matter which cannot be got rid of, and chronic catarrh results. The stones and seeds of fruits, as cherry- and plum-stones, raspberry- and currant-seeds, husks of corn and oats, produce acute or chronic constipation with serious symptoms. Intestinal worms (generally lumbricoids) when in large numbers cause obstruction of the bowel;[8] and various foreign substances taken by caprice or to take the place of food have produced the same result: among these stick cinnamon,[9] sawdust,[10] and clay (among the clay-eaters of the South) have been mentioned. Magnesia, insoluble pills, and other medicines sometimes form concretions in the bowel. Enteroliths and accidental concretions form in the intestinal canal and are sources of obstruction. Any foreign body is a nucleus around which concentric layers of phosphate of lime are deposited, and thus a hard calculus is formed. Gall-stones may pass into the canal and there accumulate in such numbers as to interfere with the passage of the fecal matter.

[Footnote 8: Copland, _Medical Repository_, vol. xvii. p. 243.]

[Footnote 9: Ware, _Boston Med. and Surgical Journal_, 1858, vol. lviii. p. 501.]

[Footnote 10: Bonney, _ibid._, 1859, vol. lix. p. 39.]

PATHOLOGICAL ANATOMY.--In cases where constipation has lasted many years no alteration of the parts involved may be found. When lesions do occur the pathological anatomy includes changes in the position,[11] calibre, and in the walls and contents of the intestines. The most common displacement is that of the transverse colon, which is depressed in its centre; the acute angle of the descending part may reach as far down as the hypogastrium. The cæcum sometimes lies in the centre of the abdomen. Dislocations of the intestines are congenital, due to anomalies of intra-uterine development, in which case they become causes of death in newly-born children from obstruction, or if insufficient to cause death they establish habitual and incurable constipation; or constipation may bring about displacement by the greater weight of a portion of the bowel constantly loaded with fecal matter.

[Footnote 11: Vötsch, _Koprostase_, Erlangen, 1874.]

The sigmoid flexure is usually the seat of the greatest dilatation; its expansion may be a cause or a consequence of constipation.[12] It may reach a maximum of distension when it fills the entire abdominal cavity, compressing all the abdominal organs and pushing the stomach, liver, {644} and intestines into the thorax. In a case of this kind the circumference of the dilated part was twenty-seven inches.[13] The descending colon may be distended with the sigmoid flexure, or the whole colon may be dilated from the upper part of the rectum to the cæcum;[14] the same thing happens rarely in the small intestine. In one case, in which there was an accumulation of feces in the sigmoid flexure, the large intestine presented itself as two immense cylinders lying side by side, extending from the epigastrium to the pelvis.[15] Each was about five and a half inches in diameter, and together they filled the abdominal cavity. The circumference of the stretched colon varies from ten to thirty inches. Pouches forming little rounded tumors are seen on the outer surface of the colon; they are sometimes hernial protrusions of the mucous membrane through the muscular coat (Wilks and Moxon), or if large they are dilatations of the pouches of the colon.[16]

[Footnote 12: Trastour, "De la Dilatation passive de l'Iliaque, et de ses conséquences," _Journal de Méd. de l'Ouest_, 1878-79, tome xii. p. 165.]

[Footnote 13: Dupleix, _Le Progrès médicale_, Paris, 1877, tome v. p. 953.]

[Footnote 14: Peacock, "Fatal Constipation, with Excessive Dilatation of the Colon," _Tr. Path. Soc. London_, vol. xxiii. p. 104.]

[Footnote 15: Lewitt, _Chicago Med. Journ._, vol. xxiv., 1867, p. 359.]

[Footnote 16: Gay, "Sacculated Colon, Prolonged Constipation," _Tr. Path. Soc. London_, vol. v. p. 174.]

The colon is sometimes much lengthened. But little weight can be attached to this anomaly, as there is a difference in the length of the colon in different nations and individuals, depending upon the character of the food, being longer in those who eat largely of vegetable food.[17]

[Footnote 17: _Ziemssen's Cyclopædia_, vol. vii. p. 606.]

The mucous membrane is normal or hyperæmic, or is in various stages of chronic catarrh. Proctitis may exist with follicular ulcers; ulcers form in the cæcum, sigmoid flexure, and in the bends of the colon; perforations and peritonitis rarely occur. Chronic peritonitis has resulted from the stretching of the bowel from retained and hardened feces; adhesions may form which ultimately cause death by obstructing the canal. The walls of the intestines are in long-standing cases much thinned. There are many reasons to believe that fatty degeneration of the smooth muscular fibre takes place, in consequence of which it loses its contractile power and atrophies. This lesion is most common in advanced life, and accompanies fatty accumulation and degeneration elsewhere. Its results would be constipation, distension of the bowel with gas, and sometimes symptoms of intestinal obstruction.[18] A thinned and dilated bowel may easily be lacerated under unusual stimulation, as from a purgative. In a case recently seen by the writer such an accident, rupture of the colon and death from peritonitis, occurred from the effects of an active purge taken to bring on abortion. Hypertrophy of the wall, especially of the muscular coat, coexists with dilatation, and is most common in the upper part of the rectum and sigmoid flexure. It is caused by overwork in expelling fecal accumulations. The walls never become as much thickened as in constipation from organic stricture.

[Footnote 18: Cases are recorded of death with symptoms of intestinal obstruction in which no lesion was found beyond a dilated colon; as, for example, in _British Medical Journal_, April, 1879, p. 621.]

Collections of fecal matter may be found in any portion of the colon, but more frequently in the rectum, sigmoid flexure, descending or {645} transverse colon, or cæcum. They lie within the intestinal tube, partly or wholly occluding it, or within lateral pouches, forming tumors which are sometimes quite large. In this last form there is no obstacle to the free passage of feces along the canal. Fecal accumulations occur as small round, oval, or irregularly-shaped lumps (scybalæ), and are often covered with layers of transparent semi-fluid mucus, puriform mucus, or mucus in filaments. The small concretions vary in density; they may be so hard as to resist the knife, and may be mistaken for gall-stones; larger masses, semi-solid or solid, are most commonly seen in the rectum and sigmoid flexure. Here the collection may reach an immense size. In one case fifteen quarts of semi-solid, greenish-colored fecal matter were removed at the autopsy.[19] In two other cases the weight of the feces found in the bowel was thirteen and a half[20] and twenty-six pounds[21] respectively. The whole colon from the anus to the cæcum may be filled with such a mass, as in a case mentioned by Bristowe, where the colon "was completely full of semi-solid olive-green colored feces. The small intestines were also considerably distended, ... and were filled throughout with semi-fluid olive-green contents."[22]

[Footnote 19: Peacock, _Tr. Path. Soc. London_, vol. xxiii. p. 104.]

[Footnote 20: Lamazurier, _Archives générales_, Paris, 1824, t. iv. p. 410.]

[Footnote 21: Chelius, _Heidelberg Med. Ann._, 1838, vol. iv. p. 55.]

[Footnote 22: Bristowe, "Diseases of Intestines and Peritoneum," _Wood's Library_, New York, 1879, p. 21.]

The color of these collections is black, reddish, deep green, or yellow. In composition the scybalæ, concretions, and larger masses consist of fecal matter, with unaltered vegetable fibre; they may be composed partly of skins of grapes, cherry-stones, biliary calculi, hair, woody fibre, magnesia, or other foreign substances. Where fecal concretions long remain in the intestine they acquire a hardness like stone, and can with the microscope only be distinguished from mineral matter.[23] Hemorrhoidal tumors, anal fissures, perirectal abscesses, fistulæ communicating externally or with the gut, are found in connection with constipation. Abscess of the iliac fossa has been observed in the same relationship.[24]

[Footnote 23: A remarkable case is recorded (_Dictionnaire de Médecine_, Paris, 1834, t. viii. p. 435) in which an ulcerating cancer of the fundus of the uterus had opened communication and formed adhesions with the small intestine, from whence the feces passed into the uterus and out through the vagina. The large intestine, totally occluded, contained petrified fecal matter.]

[Footnote 24: Richet, "Abscess of Iliac Fossa," _Revue de Thérapeutique médico-chirurgicale_, 1876, p. 563.]

SYMPTOMS.--In persons who have a daily movement an occasional interruption of two to four days may take place without local or general signs of inconvenience. It is often asserted by patients that one day's omission induces suffering, and recourse is immediately had to laxatives. This may be justified sometimes, but in the majority of cases no actual suffering follows a very rare and short constipation.[25] If, however, symptoms do occur after a constipation of one to three days, there is a sense of fulness and heat about the rectum which is greater after stool; when the bowels are moved, it is with effort (provided that no enema or purgative has been taken), and the bulk of the expelled mass is much greater {646} than usual, being moulded and hardened from its longer retention in the rectum. The margins of the anus are tender, and the unsatisfied feeling after stool is due to distension of the hemorrhoidal veins and oedema of the tissues around them--a condition which ends in painful or bleeding hemorrhoids. There are signs of impaired digestion, loss of appetite, a coated tongue, oppression after eating and flatulence, and distension of the abdomen. Headache is apt to be present, with flushing of the face and general discomfort or irritability of temper. These phenomena may all disappear within two or three days by a spontaneous stool or by the use of a purgative.

[Footnote 25: Some interesting remarks in connection with the idea that constipation is not necessarily hurtful, and is in some cases beneficial, may be found in a pamphlet by C. I. Harris, _Is our Physiology of the Large Intestine correct, and is Constipation in certain cases as Injurious as is supposed?_ London, 1878.]

Acute symptoms of a violent nature are sometimes developed in persons who have been constipated a long or short time, in consequence of attempts at purgation or from the accumulation of indigestible food. Violent paroxysmal pains in the abdomen and efforts at stool are soon followed by symptoms of intestinal obstruction and serious collapse. Quick relief follows a free movement from the bowels obtained by an enema, or if not so relieved the case may terminate fatally.

A frequent recurrence of fecal retention from the causes mentioned will in time develop the constipated habit. Distension of the rectum increases its capacity and destroys its sensibility and expulsive power. The colon above the point of stoppage is distended with gas and weakened. The bowels are rarely moved spontaneously, and finally are never emptied without artificial aid. The literature of medicine contains many extraordinary records of prolonged fecal retention, ranging from a few weeks to many months.[26]

[Footnote 26: _Am. Journ. Med. Sci._, Philada., 1846, p. 260 (three months and twenty-two days); Renaudin, _Dict. des Sci. méd._, t. vi. p. 257 (four months); Strong, _Am. Journ. Med. Sci._, Oct., 1874, p. 440 (eight months and sixteen days); Valentin, _Bull. des Sci. méd._, t. x. p. 74 (nine months); Staniland, _London Med. Gaz._, vol. xi. p. 245 (seven months); _Dublin Hosp. Reports_, vol. iv. p. 303 (eight months); Inman, _Half-Yearly Abst. Med. Sci._, vol. xxxi. p. 275 (two years); Devilliers, _Journ. de Méd._, 1756, t. iv. p. 257 (two years); J. Chalmers, _Med. Gaz._, London, 1843, vol. xxi. p. 20 (three years); _Philada. Med. Museum_, 1805, vol. i. p. 304 (fourteen years).]

The evacuations in chronic constipation are harder and more dry than they should be; they are passed in masses of various sizes, and in color are brown, black, dark-green, or yellow. Sometimes a coating of mucus is on the outside, and sometimes streaks of blood, or there is an intimate admixture of mucus, giving a slimy, gelatinous appearance to the mass. Semi-digested food, as partly-altered milk, meat, or vegetable matter, is seen, and quite frequently there is an intercurrent diarrhoea which alternates with costiveness.

The local symptoms about the pelvis and anal opening and in the lower extremities come from the pressure of accumulations of feces. Thus, compression of the iliac veins delays circulation in the lower extremities; cold feet or oedema of the feet and ankles and varicose veins follow. If the pressure is on the ilio-hypogastric and ilio-inguinal nerves, there are neuralgic pains in the groin and over the crest of the ilium. The sciatic and crural nerves may be the seats of pain. Varicocele is the effect of weight upon the spermatic veins. Erections and seminal emissions in men follow pressure on the pubic veins and prostatic portion of the urethra. Retention of urine also may come from the latter cause. If the kidneys and ureters are compressed by fecal tumors in the descending or transverse {647} colon, nephritic pain, albuminuria, or retraction of the testicle, with delay in the escape of urine, may happen. Icterus and its consequences are owing to pressure on the common bile-duct; the liver and other organs may be displaced and the aortic circulation obstructed by fecal compression. In women the retention of fecal matter in the rectum is the source of special symptoms; it contributes largely to the occurrence of cervical anti-flexion in the soft, pliable, growing uterus of girlhood (Thomas), and unites with retroversion in women who have borne children to produce great suffering.

An unnatural state of the digestive system, as a cause or result, is the invariable accompaniment of chronic constipation. The appetite is wanting; the tongue is coated, and may be pale, soft, and indented by the teeth. Distress follows eating; the abdomen is distended with gas and is hard; all the evidences of gastric or intestinal indigestion may be found. Nutrition is imperfect, as is shown in loss of flesh and in the signs of functional disorder to be next described.

The nervous system is soon deranged; sleep is unrefreshing, restless, and disturbed by dreams. There are headache and mental and physical indolence. The patient speaks of being giddy, faint, and nervous. Disturbance of vision (muscæ volitantes), of hearing (tinnitus aurium), and alarming attacks of dyspnoea and cardialgia may occur.[27] Heart-palpitations and profuse perspirations are the effect of excitement or effort of any kind. Chilliness or violent chills can be traced to this cause also. In women hysteria, disturbed menses, anæmia, and chlorosis accompany constipation.

[Footnote 27: C. C. Melhose, _Hufeland's Journal_, 1841, xcii., Stuch iv. p. 105.]

Nervous symptoms are very common in the young, and it is doubtful whether they are consequences of constipation or whether they form a part of a general state of malnutrition and anæmia. Hypochondria is undoubtedly closely connected with the constipated habit, and the failure to secure a daily movement becomes the subject of unceasing thought and anxiety. Hallucinations and sudden loss of consciousness, aphasia,[28] and delirium, have been found to depend upon fecal accumulation.[29] The absorption of fluids and gases from too-long-retained and decomposing feces may explain such cases. The nerve-centres soon show the effect of the supply of altered or contaminated blood.[30] It is probable that the marked nervous symptoms are more due to this cause than to reflex influences.

[Footnote 28: Mattei, "Aphasia cured by relieving Constipation," _Bull. de l'Acad. de Méd._, Paris, t. xxx., 1864-65, p. 870.]

[Footnote 29: Pulitzer, _Wien. med. Presse_, 1866, x. p. 439. Case.--A man æt. 42, with sleeplessness, hypochondriasis, hallucinations, and one attack of sudden loss of consciousness; symptoms relieved by removing a large quantity of fetid fecal matter from bowels. Also Dujardin-Beaumetz, serious nervous symptoms due to constipation (_Bullétin de Thérap._, Paris, t. 89, 1875, p. 179).]

[Footnote 30: Bell, _Lancet_, London, 1880, i. 243-283.]

A coincidence exists between dislocation of the colon and various states of mental disturbance. Ten cases of suicide were seen by Vötsch in which there were displacements of the colon. Laudenberger of Stuttgart found that in ninety-four autopsies of insane persons there were anomalies of position of the transverse colon in one-seventh of the number (Vötsch).

Fever is not infrequently due to constipation. During the course of typhoid and other fevers an unusual elevation of temperature is often {648} traced to a neglect to have the bowels emptied. But very high temperature sometimes depends upon constipation alone, and is at once reduced by removing the cause. This may occur in the course of chronic diseases or in health, especially in children.[31] The temperature rises from normal to 104° F., and even higher, and immediately drops to normal when the bowels are moved. When a sudden rise in temperature comes with acute constipation, the influence must be a reflected one from the mucous surface to the heat-centre.

[Footnote 31: F. Barnes, "On the Pyrexial Effects of Constipation," _Med. Press and Circular_, 1879, N. S. xxviii. p. 477. Also, C. H. Jones, _Lancet_, London, 1879, ii. p. 229--a case in which there was a temperature of 104.1°, pulse 180, and delirium due to scybalæ in bowel; Cabot and Warren, "High Temperature from Constipation," _Boston Med. and Surg. Journ._, 1880, ciii. p. 1571.]

The urine is dark-colored and scanty, loaded often with urates, or it may be limpid and of a very low specific gravity. The escape from the bladder and through the ureters may be obstructed by compression, as already mentioned. Suppression of urine has occurred, and been relieved by removing large fecal collections.[32] In women catamenial irregularity and dysuria are generally associated with constipation. Disturbances in pelvic circulation and local pressure of a distended rectum explain these conditions.

[Footnote 32: Barnwell, _Cincin. Med. News_, 1875, vol. viii. p. 353--female æt. 45. Had no movement for five days; suffered with tympanites; severe pain in right iliac region, with persistent vomiting; tumor in same region; complete suppression of urine. At the end fifth day passed large quantity of apple-peelings and fecal matter. Return of flow of urine; passed two gallons in ten hours.]

The skin is often parched, sallow, and is sometimes covered with eruptions, as acne, psoriasis, eczema, erythema, or prurigo. Injuries, wounds, and cracks of the skin heal slowly.

RESULTS AND COMPLICATIONS.--The lateral pouches of the colon, most commonly at the sigmoid flexure, become distended, and deeper pouches are formed, where fecal matter is retained.[33] This need not interfere with the regular daily movements. Fecal tumors are thus formed, the nature of which is often not recognized. The colon may be distended so as to fill a large part of the abdomen. The pressure of hardened feces brings about ulceration of the mucous membrane, perforation and extravasation of the contents into the abdominal cavity, with fatal peritonitis. Abscesses in the perirectal tissues, with fistulæ,[34] anal fissures, hemorrhoids, prolapse of the rectum, varices of the prostate gland and bladder, owe their origin to fecal collections, especially in advanced life.

[Footnote 33: Long, _Med. Times and Gazette_, 1856, vol. ii. p. 286.]

[Footnote 34: Bannerot, C., _Du Phlegmon pelvi-rectal inférieure et de la Fistule de l'Anus consécutive causées par la Constipation_, Paris, 1880.]