Volume 2 — DISEASES OF THE DIGESTIVE SYSTEM. (continued 11)

Intestinal digestion begins when the softened mass passes through the pylorus. This mass (chyme) is composed of (1) the products of gastric digestion which have not been absorbed—peptone, dextrose, levulose, peptonized gelatin, with mucus and gastric juice; (2) all matters which have escaped digestion—the starch of vegetable substances, dissolved gelatin and albumen which have not been peptonized, and some unaltered muscle-structure; and (3) fat, fatty acids, and cellulose upon which neither saliva nor gastric juice has had any influence (Ewald).

This complex semi-fluid mass with an acid reaction enters the duodenum and comes in contact with fluids and ferments destined to work remarkable changes in its composition. The first of these fluids is the bile, which is alkaline and composed of the glycocholate and taurocholate of sodium, cholesterin, soaps, etc., phosphates and carbonates of lime and sodium, chlorides of potassium and sodium, bile-pigment, etc. The outflow of bile is excited by the contact of the chyme with the orifice of the bile-duct. When the alkaline bile is mingled with the acid mass in the duodenum, it neutralizes its acidity, precipitates the peptones, and therefore stops all further action of the gastric juice. Fats containing free fatty acids are emulsified, soaps being formed by a combination of the alkalies of the bile with the fatty acids. Lastly, bile hinders fermentation in the intestine and acts as a purgative by exciting peristalsis. Absorption is probably also favored by bile, as it has been found that emulsified fats pass more readily through an animal membrane which has been wet with bile.³

³ Ewald thinks this result is doubtful: in animals killed during digestion he has found an acid reaction in the contents of the intestine beyond the opening of the bile-duct, with no precipitation of the albumen (op. cit., p. 82).

As far as we now know, the function of the bile is to neutralize the acidity of the duodenal contents, and thus pave the way for the action of a digesting fluid of much greater potency and of much higher function.⁴

⁴ In order still further to demonstrate the necessity of bile-action as a preparation for pancreatic digestion, it may be mentioned that in artificial experiments, with a heat equal to that of the body, if antiseptics analogous to gastric juice and bile are not used, there is a too rapid change from alkalinity to acidity, and consequently all of the starch is not converted into sugar before it develops lactic acid with putrefactive disorganization. A deficiency of bile, therefore, is a cause of intestinal indigestion (Bartlett, op. cit., pp. 12, 13).

This fluid, the pancreatic juice, is composed of inorganic salts, albuminoids, and certain specific ferments, and has an alkaline reaction. It has a threefold operation upon the softened mass with which it now comes in contact: 1. The starch of vegetable matter, which has been only slightly acted on up to this time, is now rapidly converted into grape-sugar by a peculiar diastatic ferment more active than any other known ferment. 2. Albuminous matters (proteids) which have escaped digestion in the stomach are changed into a soluble and absorbable pancreas—peptone. Trypsin is the active ferment in this case (Kühne), and it is only in alkaline or neutral solutions that the albuminoids are readily dissolved. The necessity of neutralization by the alkaline bile is thus demonstrated. 3. A ferment distinct from the others splits the fats into fatty acids and glycerin, and emulsifies them so that they can be taken up by the lacteals lower down.

Experiments made by mixing albuminates with pancreatic gland-extract, under favorable conditions, show after a certain time the presence of leucin, tyrosin, hypoxanthin, and asparaginic acid. In a feebly alkaline or neutral solution a faint putrefactive odor is soon noticed, with the development of bacteria; ammonia, sulphuretted hydrogen, hydrogen, and carbonic acid—evidences of the putrefaction of albumen—are also detected.

It is difficult to tell when normal digestion in the intestines ends and putrefaction begins. The conclusion is, that the normal action of pancreatic juice (trypsin) gives origin to bodies met with in the ordinary putrefaction of albumen.⁵ This thin border-line between normal intestinal digestion and the decomposition of the intestinal contents has an important bearing on the facts of intestinal indigestion.

⁵ Ewald, op. cit., p. 92.

The intestinal juice performs a minor but independent part in digestion. It converts albuminous matter into peptone, and hydrated starch into sugar. Its function is therefore supplementary to that of the gastric and pancreatic secretions.⁶

⁶ Ewald, op. cit., p. 103; also, "The Functions of the Intestinal Juice," Charles L. Dana, Med. News, Philada., July 15, 1882, p. 59.

When food enters the mouth the process of digestion begins, and all the activities of the glands concerned in digestion are probably at once set in motion. Mastication excites, by reflex action, pancreatic secretion; the acid chyme touches the orifice of the common bile-duct and stimulates the outflow of bile; the neutralized chyme next invites pancreatic digestion. For the integrity of intestinal digestion it is required that mastication and stomach digestion should be normally performed.

The intestinal movements which are so necessary to digestion by making successive changes in the position of the intestinal contents are controlled by nervous arrangements, but may occur independently of the central nervous system. The ganglia of Auerbach and of Meissner in the intestinal wall are sufficient for the development of peristaltic waves. The irritation of the mucous membrane by food, hyperæmia, and the pouring out of digestive juices, and intestinal movements, are parts of one process. Paralysis by section of the splanchnic leads to hyperæmia of the intestinal vessels and increased peristalsis; stimulation of the splanchnic causes anæmia of the intestinal wall and arrest of movement. Local cold by producing anæmia brings about the same result.

The products of digestion as they pass toward the jejunum consist of diffusible peptones, sugar, emulsified fats and oils, and substances which have escaped digestion, as fragments of muscular fibre, starch-corpuscles, connective tissue, hairs, or other foreign matters. The bowel contains also carbonic acid, hydrogen, nitrogen, sulphuretted hydrogen, and marsh gas. The mass, alkaline or neutral in the duodenum and jejunum, becomes acid in the ileum from the putrefaction of albumen and fermentation. The peptones and sugar pass by osmosis into the blood-vessels of the portal system and thence to the liver. In the liver the sugar is converted into glycogen (carbohydrate), and stored in the liver-cells until needed for the maintenance of animal heat and for the nutrition of the tissues. The peptones are used in part to supply the nitrogenous waste of tissue, but much of the albuminoid matter is broken up in the liver into glycogen and urea, the latter of which is excreted by the kidneys as waste matter.

The minute granules of oil in emulsion are taken up by the epithelial cells covering the villi; thence they enter the adenoid tissue of the villi on their way to the lymphatic radicles, the lacteals. From here the passage is open to the underlying lymphatic vessels and to the larger abdominal lymph-vessels and the thoracic duct beyond.

Intestinal digestion is not completed and the body does not receive its pabulum until the products of digestion have reached the liver and the thoracic duct.

ETIOLOGY.—It is usually said that intestinal dyspepsia is more common in women than in men, but the contrary is the rule. Some of its most common causes—over-eating and the eating of indigestible food—are especially vices of men.

It is more frequent between the ages of forty and fifty, but no age is exempt. Infants at the breast, children of any age, adults, and old men and women are alike subject to it. Men in middle life begin to suffer from the imprudence and carelessness of youth and from the anxiety and cares of business. The indulged children of rich parents and improperly bottle-fed infants frequently suffer.

Heredity and idiosyncrasy have a certain influence in determining the prevalence of intestinal dyspepsia. The distaste for and inability to digest vegetables, fruits, and fats are often peculiarities of family history. The occurrence of cases in the same family is often explained by improper food, bad cooking, and irregular hours, to the evil influences of which all the members are similarly subjected.

All conditions of the organism which result in a depraved or altered blood-supply, as anæmia, primary and secondary rachitis, chronic syphilis, and continued febrile diseases, are causes of intestinal indigestion. The connection of the indigestion of fats with the strumous diathesis and with phthisis is undisputed. J. Hughes Bennett traced the origin of phthisis to defective fat-digestion; strumous indigestion and the indigestion of fat are synonymous terms.

Debilitating influences, such as bad air, want of cleanliness and outdoor exercise, impair functional activity in the intestines as elsewhere. Sexual excesses, but especially masturbation, have a special influence for evil in this direction.

The influence of the mind upon the digestion of starch and fats is even greater than upon gastric digestion, for no other reason perhaps than that the former is a more complex function and less easily relieved than the latter. Prolonged or excessive mental labor does not do so much harm as mental worry, over-anxiety, and the strain and overwork of business. Professional men—lawyers, physicians, and clergymen—who become over-burdened with responsibilities, and who sympathize too much with the distresses of others, are very prone to suffer. The careworn face with lines about the mouth and forehead is one of the plainest signs of duodenal defect. The proper secretion of the juices of the intestine and normal peristalsis are impossible where brain and nerves get no rest. The too rapid mental development of the children of the present day is a fruitful source of weakened fat-and-starch digestion and of impaired development. So long as children are sent to the public school at four and six years of age, there will continue to grow up a precocious race with active brains in feeble bodies.⁷ This injurious result is largely brought about by the direct interference of premature brain-development with the complex intestinal processes of digestion and absorption.

⁷ In eight of the States and Territories the minimum age for entering the public school is fixed at four years; in seventeen States at five years; in the others, except two, at six years. The two notable exceptions are Alabama and New Mexico, where children do not enter school until the age of seven.

Wealth, with ease and inactivity, and sedentary occupations, contribute to the same end by lessening the need of food, and thus debilitating the organs of digestion by inaction. Sedentary pursuits, especially those in which the body is bent forward and constricted or compressed at the waist, interfere with active function in the intestine. This is the case in tailors, shoemakers, etc. Tight-lacing in women and a too tight trouser-band in men are injurious.

Hot climates, especially when combined with dampness, lead to disorder in the intestine and liver. This effect is most marked among persons coming from colder climates, as among the English in India, who keep up the habits of eating to which they have been accustomed at home. The lessened demand destroys the appetite, and stimulants and condiments are resorted to to whip up the inactive functions. The intestine is loaded with a mass of crude, unaltered matter which can with difficulty be disposed of. Chronic indigestion results, varied with acute attacks of diarrhoea or dysentery. The portal system is filled with an excess of albuminoid material which the liver is unable to store away. The excess is got rid of by conversion into uric acid. Lithæmia and chronic congestion and enlargement of the overloaded liver result, with their many attendant evils.

Over-eating occasions first gastric and then intestinal indigestion by the entrance of unaltered food into the duodenum. Eating without hunger often involves the taking of food which the body does not need and which the stomach cannot digest. Diners-out rarely go through a season without one or more internal revolts. A too-varied diet, a dinner of many dishes, is faulty in variety as well as in excess. On the other hand, a too great sameness in diet and the prolonged use of one or two articles of food which are not easy of digestion, and which have a great deal of waste, fatigue and then disorder intestinal digestion. This is a fault into which children are often allowed to fall.

Indigestible food and an excess of starchy or fatty food conduce to disorder of duodenal digestion. In conditions of debility and anæmia and in the convalescence of fevers the deficiency of saliva involves an inability to digest starch in the mouth and points to a corresponding want in the duodenal secretions. The improper use of alcoholic liquors, taking them on an empty stomach between meals and in excess, tends to direct irritation of the mucous tract. Condiments in large quantity have the same effect.

Irregularity in the hours of eating and a faulty distribution of the amount of food disturb the perfect working of the mechanism of digestion. Very light breakfasts and very late and large dinners are injurious. The habit, now quite general in cities, of deferring the breakfast proper until midday, leaves the system too long—fifteen to sixteen hours—without proper food and weakens digestive activity. Intestinal indigestion is very common among Americans who have lived abroad and adopted European customs.

Another cause which is unfortunately very common is the imperfect mastication and insalivation of food, due to too great haste in eating, to defects in the teeth or gums, or to a deficiency of saliva. The saliva no doubt sometimes possesses a feeble diastatic power, although abundant in amount. Carnivorous animals bolt their food, but vegetable-eaters must masticate. Slow mastication transforms starch into sugar, and at the same time excites secretive activity in the glands of the digestive tract, especially in the pancreas. The more thoroughly this preliminary function is performed the better preparation is there for the subsequent acts of digestion.⁸

⁸ "The familiar act of chewing is seldom a subject of reflection, yet it throws into motion a more complicated system of levers, accompanied by a drain of fluids from more curiously adapted apparatus, than the arts can parallel" (Leared, On Indigestion, London, 1863, p. 3).

The chewing of tobacco, a wretched habit which is much less common now than formerly, and to a less extent the habit of smoking, are causes of deficient, altered, or depraved saliva, and secondarily of altered pancreatic secretion. The thin smoker grows fat when he abandons the weed.

The normal functions of the intestines are interfered with and indigestion is set up by constipation. Every one has felt the activity in digestion which accompanies the regular habit of defecation, and the torpor and oppression which depend upon an unemptied colon. "There is a concert of action in virtue of which the whole muscular apparatus of the digestive tube sympathizes with that of the large intestine. This concert of action, which induces pathological states, is the reason why in the physiological state a regular contraction of the whole intestinal tube, including the stomach, is the consequence of the regular contraction of the large intestine."⁹

⁹ Trousseau, "Les Dyspepsies," L'Union médicale, tome xi., 1857, p. 313.

An excess of acid in the stomach would enfeeble the solvent power of the intestinal fluids by antagonizing neutralization by the alkaline bile; the same effect follows any cause which prevents the outflow of the bile, as the plugging of the common bile-duct by mucus and epithelium in catarrh or by an impacted gall-stone. The emulsification of fats is incomplete and decomposition in the intestine follows. The antagonism of the saliva and the gastric juice, of the gastric juice (or the chyme) and the bile, must preserve their delicate and nice adjustment in order for digestion to be properly performed.

Diseases of the pancreas seriously embarrass digestion in the intestine. Lesions of this organ, as catarrh of the duct, cancer, fatty degeneration, etc., may result in impaired emulsification of fats, fatty diarrhoea, and wasting.

Intestinal indigestion accompanies hyperæmia and catarrh of the intestinal mucous membrane, diseases of the heart, lungs, and liver, and all other causes which impede portal circulation.

SYMPTOMS.—Intestinal indigestion cannot be so clearly pictured as that of gastric dyspepsia. This is owing to the frequent concurrence of the two conditions, the gastric symptoms taking precedence of the others. The more complex nature of the intestinal function is another reason, intestinal indigestion having more modifications in its phenomena. In the stomach there is only one active secretion; in the intestine there are three, all participants in the act of solution. An alteration in the quality or quantity of one of these—the bile, for example—would lead to different symptomatic results than would follow another defective secretion, as that of the pancreas, for instance. Clinical study has not yet fully differentiated the forms of indigestion due to these several deficiencies. But there are certain well-defined symptoms associated with intestinal disorders which are distinguished by their seat, time of their appearance, and their character from analogous symptoms connected with the stomach.

Intestinal indigestion may be acute or chronic. The latter is the more typical and more common form.

When a sudden attack of indigestion in the intestine results from the entrance into the duodenum of food in such a state that it cannot be digested, the result is the rapid development of pain, flatulence, borborygmi, and frequently of fever, ending in diarrhoea, with the escape perhaps of the offending matter: a condition then exists which may be called acute or subacute intestinal catarrh or acute intestinal indigestion. One name would be as correct as the other. Slight acute forms are marked by a coated tongue, loss of appetite, headache, pains in the limbs, distress in the epigastrium or right hypochondrium, flatulence, and constipation. These might be accompanied by symptoms indicating a disorder of the liver functions—light-colored stools, slight jaundice, lithates in the urine. But intestinal indigestion alone can cause these symptoms without the condition of so-called biliousness being present. The local symptoms are due to the presence in the intestine of an imperfectly-altered mass and the development of gas; some of the general symptoms are reflex; others, as headache and lassitude and pain in the limbs, come from the absorption into the blood of the gases, particularly sulphuretted hydrogen. The participation of the stomach in acute attacks of this sort modifies the symptoms as here described. Such attacks are apt to recur at intervals.

If the causes which bring about acute disorder in the intestine are allowed to continue, the intervals between the acute or subacute attacks diminish, and there is in time a fixed state of chronic intestinal dyspepsia in which the partly-altered food coming from the stomach is not properly prepared for absorption. Instead of digestion there is decomposition; the transition is easy from the one to the other of these states. The symptoms connected in this case with the digestive organs are pain, occurring from two to six hours after eating, in the right hypochondrium, the epigastrium, or the umbilical region, due to distension of the intestine with gas. This pain is dull, not always fixed, lasts from one to three hours, and is accompanied by tenderness on pressure over its seat.

Tympanites, borborygmi, and a sensation of fulness in the abdomen accompany the pain or may exist without it. Gaseous accumulations in the intestine, the cause of these symptoms, have an independent source, being produced by decomposition in the gut itself, and are not due to the descent of gases from the stomach through the pylorus. What is a physiological and temporary condition becomes in disease a distressing symptom of long duration. In intestinal indigestion the gut is nearly always inflated with gas, which in its movement produces rumbling noises. In acute indigestion it is rapidly formed in large amount, and by the stretching of the wall of the bowel and pressure on nerve-filaments causes intense pain—colic. In the chronic form the distension excites uneasy sensations, prevents sleep, and may be so great as to cause dyspnoea by pushing the diaphragm upward. When the small intestine is distended the greatest swelling may be about the umbilicus, or the abdomen may be evenly rounded. When the colon is chiefly or solely inflated, its outline across the upper part or at the sides of the abdomen can be easily made out.

Constipation is a common feature. It is produced by a loss of contractility of the intestinal wall. The more direct causes are over-distension of the gut and disturbance in the circulation and innervation of its walls. The stools are hard and dry, and are expelled with difficulty. Sometimes they are coated with shreds or films of mucus, the product of a chronic catarrh of the mucous membrane of the colon, or mucus from the small intestine is intimately mixed with the mass. Diarrhoea may alternate with constipation. The passage of unaltered food, as fragments of meat, vegetables, or fruit, clearly shows the extent to which indigestion exists. By the microscope particles of food which have escaped complete disintegration may be detected. The stools vary in color. Very dark-green or black discharges show an excess of bile; light-yellow or gray slate-colored, a deficiency. Stools of the latter character are highly offensive in odor.

Hemorrhoids are often present, being due to the sluggish portal circulation and to the pressure of hard fecal masses in the rectum. The appetite is not impaired, as a rule, but it may be fitful or irregular. A bad taste in the mouth, and a swollen, relaxed, and coated tongue may exist without any decided gastric disease.

The symptoms of disorder of the nervous system are more marked than in gastric dyspepsia. This results not so much from the depressing influences of pain as from the peculiar malnutrition of the nerve-tissue. In order to have furnished to the blood the pabulum out of which the nerve-elements are reconstructed the digestion of fat must be normally performed. Lecithin, which is found conspicuously in the brain and nerves, is a complex fat containing phosphorus and nitrogen.¹⁰ Anæmia and waste follow directly from interference with the digestion and absorption of fats and starch in the intestine, but the most delicate, the most easily-disorganized solid of the body, the nerve-tissue, is the first to feel and to manifest its want of natural supply. And so the dyspeptic whose intestine is at fault becomes depressed in spirits, hypochondriacal, absorbed in the contemplation of his sufferings, analyzing them and referring them to the most serious organic changes. There are sleeplessness, disturbing dreams, the habit of waking at a fixed hour, dizziness, uneasy sensations or pain in the head, and disturbances of the special senses, as buzzing in the ears, muscæ volitantes, and attacks of blindness. Headache assumes often the form of hemicrania; it may be in the forehead or about the eyes. Attacks of vertigo and sensations as if the ground were rising beneath the feet accompany intestinal flatulence. Confusion of thought, loss of the power of application, and mental inertia are frequent sources of anxiety. Paralysis has been noted as following indigestion. Epileptiform convulsions and milder epileptic attacks can be traced to undigested matter in the intestine.¹¹ Various modifications of general sensibility also happen: there are pains in the back and limbs, hyperæsthesia, and anæsthesia. An inaptitude for exertion, especially for mental labor, forces the boy to give up school and college life. Successful careers are abandoned by men who at the cost of neglecting all the rules of health have succeeded for a brief period in passing their fellows in the race. Sudden attacks of fainting have been noted, with very grave collapse. These are the effect upon the nervous centres of the absorption of sulphuretted hydrogen which has been evolved in large quantities in the intestine.¹² The daily occurrence of vertiginous and other morbid sensations, with melancholia, may be due to the daily toxic absorption of gas from the intestine.

¹⁰ Fothergill, Indigestion and Biliousness, New York, 1881, p. 76.

¹¹ Chambers, The Indigestions, London, 1867, pp. 305-307.

¹² Tyrell, case of a man with eructations smelling of sulphuretted hydrogen who had vertigo and sudden collapse; symptoms relieved by purgative (Pacific Med. and Surg. Journ., May, 1882, p. 539).

The action of the heart is disturbed as in stomach indigestion. Irritability of the heart and palpitation are in part due to anæmia and in part to mechanical pressure and reflex influences. The nervous, anæmic, thin dyspeptic has among his chief troubles a throbbing heart, which keeps him awake at night and fixes his attention upon this organ as the seat of his disease. The general circulation is languid; cold hands and feet and cold sweats testify to this, and the irregularity or suppression of catamenia follows upon the irregular blood-supply.

The urine is usually high-colored, has an abnormally high density, is acid, and on cooling deposits lithates, uric acid, and oxalate-of-lime crystals. The urine is most heavily loaded with sediment when digestion has been recently completed. Therefore, the morning urine after a heavy dinner of the night before contains the largest amount of lithates. Albuminuria is occasionally a symptom of indigestion in the bowel. The eating of cheese or pastry in excess may cause it.¹³ Seminal emissions at night frequently occur. The action and reaction upon each other of this perversion of the sexual function, the indigestion, and the mental disorder, reduce the poor sufferer to a most pitiable condition of despondency and prostration.¹⁴

¹³ Warburton Begbie's Works, Sydenham Society's Publications, 1882, p. 359.

¹⁴ The writer has observed cases in which an exaggeration of the sexual instinct in men of middle age was associated with intestinal indigestion.

Anæmia is one of the earliest indications of impaired nutrition. It precedes loss of flesh and the wrinkled and dry condition of the skin which may be a marked symptom in cases of long standing. Various eruptions appear on the skin. In the strumous dyspepsia of children the white, almost waxy, skin is covered with dry scales, which may be seen over the whole body from head to foot. No symptom is more characteristic of intestinal indigestion and of imperfect fat digestion and absorption than this. Eczema and psoriasis, pityriasis, impetigo, and porrigo decalvans are forms of skin eruption seen.

Closely allied to the symptoms caused by indigestion in the intestine are those due to functional disorder of the liver. The liver completes the work which the intestine has begun. It receives directly from the intestine blood laden with the products of digestion, and further transforms them into substances to be used in the economy. The symptoms which result from disturbances in the performance of these functions are, as has been said, closely connected with the symptoms of intestinal indigestion. This association is shown by the tendency among older writers to trace all such symptoms to the liver, the terms bilious and biliousness including all the phenomena of derangement of the function of digestion in the intestine, as well of the function of the liver. Later writers excluded the part of the liver to a great extent in giving rise to the so-called bilious symptoms. Recent physiological study has shown how closely the intestine and the liver are associated in health and in disease. When the liver is implicated in indigestion the symptoms which follow are due either to a deficiency of the secretion of bile, and the resultant disturbance of digestion in the intestine, or to a derangement in the transformation in the liver of the products of albuminoid digestion. When the disorganization of the peptones is imperfectly performed in the liver, instead of urea there is a production of lithates and lithic acid, constituting the condition called lithæmia. The lithates pass into the urine and are deposited. The occurrence of this urinary sediment after excesses and imprudences in diet is well known. The continuance of lithæmia leads to the development of symptoms more or less characteristic. These are a loss of appetite and coated tongue, flatulence, oppression after eating, and constipation. The nervous system is soon disturbed, and often to a marked extent. Vertigo, headache, disturbances of the special senses, sleeplessness at night, drowsiness during the day, annoy the patient and induce extreme hypochondria. He is worried, moreover, with numbness and tingling in one or both arms or in the legs, and hence spring fears of paralysis. The heart is disturbed in action, and is irregular and feeble. Emaciation in previously corpulent persons is not unfrequent.

COURSE, TERMINATION, AND SEQUELÆ.—Acute dyspepsia in the bowel lasts from a few hours to a day or two, and ends in leaving the patient as well as before. A diarrhoea of indefinite duration may follow.

Chronic intestinal indigestion in infants and young children often continues until the diet is changed to one suited to the powers of digestion. In adults interference with so important a function cannot but have the most serious results. While the progress is slow, lasting many years, there is a steady march from bad to worse.

The character and conduct are so altered by the disease that a man may be said to be just what his digestion makes him. Amiability under the daily goad of intestinal dyspepsia is an impossibility. The irreconcilables, the men out of joint with the world, are living witnesses of the antagonism and disaffection within their intestines. The deterioration in health paves the way for many diseases, and there is hardly an organ in the body which may not ultimately become the seat of organic change.

In the young, phthisis is frequently the ultimate result of the malassimilation and malnutrition; in men beyond middle life degenerative changes in the intestine, liver, and kidneys close the series of morbid changes which began in the intestine. Thomas N. Reynolds attributes bronchitis and phthisis in part to the local influence of septic matter carried by the portal and lacteal vessels to the lungs in cases of intestinal dyspepsia, with constipation and septic fermentation of the ingesta.¹⁵

¹⁵ Paper read before section of Practical Medicine at meeting of Am. Med. Assoc. in 1883.

In many cases business and professions are abandoned, and men become, under the influence of despair and complete absorption in their symptoms, intellectual and moral wrecks, burdens to themselves and to all around them. In this stage the primary cause, the dyspepsia, is lost in the exaggerated prominence of the nervous symptoms.

DIAGNOSIS.—The acute variety is known by the seat of the abdominal symptoms, the pain, distension, and movement of gas not being in the stomach, but in the intestines. The pain is like colic; the abdomen is sensitive to the touch; tympanites is general and may be very great. If vomiting occurs, the symptoms continue after the stomach is empty. Diarrhoea may quickly come on, and is followed by relief. The fever may be quite high. There is no sleep, but restlessness, and in children delirium. They may also have convulsions.

In the chronic form the history of the case and the study of the causes are of great value in formulating an opinion. The persistent abuse of the pleasures of the table sooner or later develops intestinal indigestion. Inquiry into the mode of life, hours of eating, manner of eating, kinds of food taken, etc. gives important information. The teeth are defective, and mastication and insalivation are neglected. There is distress in the pit of the stomach or in the right hypochondrium, beginning about two hours after eating and lasting from four to six hours; intestinal distension with gas, either in the small intestine or colon, with borborygmi and constipation, is generally present. The nervous symptoms are characteristic: they are depression of spirits, irritability, sleeplessness, vertigo, and headache. The man is more completely altered mentally than in gastric dyspepsia. The urine contains lithates in excess; anæmia and emaciation progress rapidly. Seminal emissions and weight and heaviness about the loins are present.

The following symptoms distinguish gastric dyspepsia, and do not occur in intestinal indigestion unless the stomach is at the same time involved: pain or weight in the epigastrium immediately after eating, vomiting of unaltered food, of food in a state of acid fermentation, eructations of ill-tasting or bad-smelling gas or of acid fluid, water-brash, and heartburn. Loss of flesh may not take place to any extent even in very bad forms.

The diagnosis of differences in the forms of indigestion due to defects in the pancreatic, biliary, or intestinal secretions is not at present a matter of precise knowledge. A pancreatic indigestion would be followed, it might be supposed invariably, by fatty stools; but such is not the case, since degeneration of the pancreas and closure of the duct have occurred without fatty evacuations from the bowels.¹⁶ Moreover, ulceration of the duodenum is followed sometimes by fat in the stools. Still, if the symptoms of intestinal indigestion include rapid wasting and fatty diarrhoea, we may conclude that the pancreas is at fault. The fat varies in appearance and amount. It may be seen as oil-drops passed alone or with fecal matter, or as lumps of fat, pale yellow and tallow-like. Glycosuria¹⁷ bears some relation to pancreatic diseases, and therefore may be an aid in diagnosis.

¹⁶ Ewald, op. cit., p. 95; D. S. Haldane, "Cancer of Pancreas," Edin. Monthly Journ. of Med. Sci., xix. 1854, p. 77; J. S. Bartrum, "Scirrhus of Pancreas and Stomach," Assoc. Med. Journ., 1855, p. 564; DaCosta, "Primary Cancer of Pancreas," Proc. Path. Soc. Philada., 1857, vol. i., 1860, p. 8; S. W. Gross, "Primary Cancer of Head of Pancreas," ibid., vol. iii., 1871, p. 94.

¹⁷ Bright, "Cases and Observation connected with Diseases of the Pancreas," Med.-Chir. Trans., vol. xviii. p. 1.

A deficient excretion of bile is indicated by a whitish or yellowish coating of the tongue, with loss of appetite and bad taste in the mouth. The stools are scanty, dry, slate-colored or white, and offensive in smell. The urine contains lithates. The complexion is pale or muddy. The nervous system is much deranged. The patient is languid, often irritable and hypochondriacal. He complains of headache, and is dull and drowsy after eating. The heart's action is unsteady, intermittent, or frequent. It is impossible to recognize indigestion due solely to a deficiency of the intestinal juice or to feeble peristalsis, granting that such forms exist.

PROGNOSIS.—A fatal result does not follow directly from intestinal indigestion. Its complications and results are frequently the causes of death. Treated early and with decision, a cure can be expected. Everything depends upon the extent to which the patient submits to the strict directions of his physician; his whole life must be made subordinate to the plan of treatment.

When the general health has become profoundly altered there is less chance to do good. Discouraging symptoms are anæmia, debility, coexisting gastric dyspepsia, an inherited hypochondriacal tendency, or the strumous diathesis in children.

When the disease has so far progressed that the patient is unable to rouse himself to the point of wishing to be well, only the most severe measures directed to the control of an irresponsible person can save him from ruin. In organic disease of the pancreas, intestine, liver, or heart the result will depend upon the nature and curability of the lesion.

TREATMENT.—Acute intestinal indigestion due to the presence of undigested food and gas in the intestine is treated by relieving present distress and procuring a free movement from the bowels. A large enema or a quick cathartic followed by an opiate—hypodermic injection of morphia, paregoric, or other preparation—may give early relief. A strict diet, warm poultices over the abdomen, and an anodyne may be needed for several days after.

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 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 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, 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.

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 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 alkaline¹⁹ 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.

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 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.

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 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.

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.

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 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 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.

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 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

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

⁵ Leube, in Ziemssen's Cyclopædia, vol. vii. p. 211.

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 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.

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.

⁸ Copland, Medical Repository, vol. xvii. p. 243.

⁹ Ware, Boston Med. and Surgical Journal, 1858, vol. lviii. p. 501.

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.

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, 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

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.

¹³ Dupleix, Le Progrès médicale, Paris, 1877, tome v. p. 953.

¹⁴ Peacock, "Fatal Constipation, with Excessive Dilatation of the Colon," Tr. Path. Soc. London, vol. xxiii. p. 104.

¹⁵ Lewitt, Chicago Med. Journ., vol. xxiv., 1867, p. 359.

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

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.

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 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 half²⁰ and twenty-six pounds²¹ 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

¹⁹ Peacock, Tr. Path. Soc. London, vol. xxiii. p. 104.

²⁰ Lamazurier, Archives générales, Paris, 1824, t. iv. p. 410.

²¹ Chelius, Heidelberg Med. Ann., 1838, vol. iv. p. 55.

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

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.

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 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.

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

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 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.

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.

²⁸ Mattei, "Aphasia cured by relieving Constipation," Bull. de l'Acad. de Méd., Paris, t. xxx., 1864-65, p. 870.

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).

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 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.

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.

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.

³³ Long, Med. Times and Gazette, 1856, vol. ii. p. 286.

³⁴ Bannerot, C., Du Phlegmon pelvi-rectal inférieure et de la Fistule de l'Anus consécutive causées par la Constipation, Paris, 1880.

Intussusception has been attributed to the weight of a mass of feces. Typhlitis and perityphlitis may come from retention in the cæcum. Pressure upon the viscera brings about derangements in their functions, many of which have already been described. From straining at stool a hernia, hæmoptysis, or cerebral hemorrhage may happen. Cases have been reported of death from rupture of an aneurism of the aorta while at stool, and J. F. Hartigan met with a case of spontaneous rupture of the aorta, where the vessel was apparently but little diseased, occurring in a man aged sixty during the act of defecation.³⁵

³⁵ Hartigan, Tr. Med. Soc. District of Columbia, vol. i. No. 3, 1874, p. 55. See also same number for a valuable paper on spontaneous rupture of aorta, by J. J. Woodward.

The effects upon the general system are those connected with malnutrition. The health may be profoundly altered and death occur from secondary diseases. Many general symptoms are due to the retention in the blood of excrementitious matters or to their reabsorption.³⁶

³⁶ Sterk, "Ueber den schudlichen einfluss der chronischen Stuhlverhatten auf den Gesamur organismus," Wien. med. Presse, xxii., 1881, p. 330 et seq.

DIAGNOSIS.—The diagnosis of constipation is not difficult except in hysterical women, who select this as one of their subjects of deception. Primary must be distinguished from secondary constipation, the last being a symptom of some general or local disease. The history of the case and the predominating symptoms will be guides to a decision, but constipation should be regarded as a symptom until it is proved to be otherwise. The tendency is to look upon it and to treat it as a distinct malady; important organic changes elsewhere may thus be overlooked. Simple habitual constipation may be mistaken for constipation due to lesions in the wall of the intestine or to closure from the external pressure of tumors.

Slowly-developed symptoms of obstruction may come from polypoid growths or benign tumors in the rectum, colon, cæcum, duodenum, and ileum. They are usually found in the rectum. The diagnosis can only be made when the growth is in the rectum or when the tumor is expelled from the bowel. Cancerous obstruction is accompanied by cachectic changes, by the presence of an abdominal or rectal tumor, the passage of blood and mucus, and violent rectal or abdominal pain. Primary cancer in the small intestine appears in the form of lymphoma; it readily ulcerates, and rather widens than narrows the channel of the bowel.³⁷

³⁷ Wilks and Moxon, Path. Anat., Philada., 1875, p. 417.

Stricture of the bowel is most commonly found low down in the rectum or sigmoid flexure, within reach of the finger or exploring bougie. If high up, it can only be diagnosed by exclusion and by its slow progression from bad to worse. Syphilis or dysentery has nearly always preceded the development of stricture.

Tumors in the abdomen or pelvis compress the colon, and while they are small they may be overlooked; sooner or later they grow so as to be recognized.

The presence of gall-stones as obstructions may not be detected until they are passed. The previous occurrence of attacks of hepatic colic, followed by jaundice, gives rise to the suspicion that gall-stones are in the intestine if they have been carefully looked for in the stool but never found.³⁸ Enteroliths give no indication by which they could be known to be in the bowel.

³⁸ In a case seen by the author three separate attacks of typhlitis occurred in a young woman suffering from chronic constipation. After the last attack she passed from the bowel several dark, irregularly-shaped concretions. The largest of these was a gall-stone covered with fecal matter. Since this time—two years ago—there has been no recurrence of inflammation and the constipation is much better.

All forms of constipation from organic modification of the walls grow worse and have no remissions; some rapidly progress toward a fatal termination. Simple constipation is subject to improvement and relapses due to the character of the food, climate, exercise, etc. The etiology is an important guide.

Stercoral tumors may be known by their position and character as ascertained by physical examinations and by their history. They are found in the iliac, lumbar, or hypochondric regions, and sometimes in other parts of the abdomen. The most common seat is in the sigmoid flexure and descending colon. They are nodulated, movable, painless, can be made to change shape or are indented by pressure, and have a doughy feel. Exploration of the rectum, by detecting impaction, will make the diagnosis clear when the obstruction is low down. The distension of the abdomen above the point of obstruction is limited at first to the region of the colon; but if the colon is much dilated with gas or is displaced, the enlargement becomes more central and more general. On percussion the sound is of a dull tympanitic quality, and never absolutely dull even in cases of great fecal accumulation.³⁹

³⁹ Case referred to by Guttmann (Physical Diagnosis, Sydenham ed., p. 360), in which the sound was dull tympanitic over two large fecal tumors which weighed when removed at the post-mortem six kilogrammes (sixteen pounds).

Fecal tumors⁴⁰ are preceded by habitual constipation, and are most common in elderly people; they are changed in position and size or made to disappear by cathartics or rectal injections. Persistent treatment will bring away scybalæ which by their color and consistence show that they have long been in the canal. But the free movement of the bowels and the non-disappearance of the tumors are no proof that they are not fecal.

⁴⁰ Tumeurs stercorales, Paris, Thèsis No. 240, 1878.

Fecal accumulations have been mistaken for ovarian tumors,⁴¹ cancerous tumors of the mesentery, uterine fibroids, and retro-uterine hæmatocele. Fecal tumors in the transverse colon have been taken for enlargement of the liver and spleen. In one instance obstruction of the bowel from fecal impaction was supposed to be a strangulated gut in a patient suffering from hernia: an operation was performed, the patient dying in sixteen hours afterward.⁴² Ovarian tumors in their early stages are sometimes thought to be fecal.⁴³

⁴¹ Jas. Y. Simpson, Med. Times and Gazette, London, 1859, vol. ii. p. 549.

⁴² Thomas Bryant, Med. Times and Gazette, London, vol. i., 1872, p. 303.

⁴³ J. B. Brown, Lancet, London, 1850, vol. ii. p. 48.

Fecal impaction in the rectum, with ulceration and bloody and mucous stools, may for a time be called cancerous ulceration. Sacculated scybalæ cannot be distinguished from submucous tumors even by the hand pressing on them in the rectum.⁴⁴