Constipation.

Synonyms.—Costiveness; Obstipation.

Definition.—The retention of fecal matter beyond the normal time, attended by great difficulty in expulsion, with a sense of insufficiency in action.

Etiology.—It is impossible to draw the dividing-line between a normal condition of the bowel and constipation; for while one well-formed stool per day is the rule, in some individuals two stools per day is the normal condition; while in others a stool every other day would be considered a condition of health. The causes are numerous, and may be described as follows:

Heredity.—Many children come into the world with a feeble constitution and weak intestinal track as their heritage; hence constipation is early developed.

Temperament.—Persons of a nervous and bilious temperament, usually pale and dark-skinned, with torpid liver, furnish conditions favorable for constipation.

Sex.—While constipation is not confined to one sex, it is very much more prevalent among females. They are more prone to neglect a regular habit, and, through false modesty, neglect the calls of nature, when in public buildings or conveyances. Also their life, as a rule, is less active than that of the male; again, frequent pregnancies weakening the abdominal muscles, or a gravid uterus pressing against the rectum, or an inflamed and prolapsed ovary, are conditions that favor costiveness.

Sedentary life, and neglect to respond to nature's call, favor this condition. In this age of competition, where the almighty dollar is the goal of the great majority of the human family, nature's call is either neglected or postponed till the bowel loses its sensitiveness, constipation naturally resulting.

Cathartics.—The habit so many Americans have, of taking liver-pills, compound cathartics, and the many bottled waters that are on the market, for every ache and pain, is responsible for a very large proportion of the cases of constipation.

Diseases.—Wasting diseases and acute fevers, also anemia and chronic diseases of the lungs, heart, and liver: neurasthenia and chronic disease of the stomach and bowels; adhesions, resulting from peritonitis, dysentery, and enteritis, whereby the bowel loses its peristaltic action; painful diseases of the rectum, such as hemorrhoids, fissures, etc., cause the patient to refrain from stool as long as possible. Catarrhal disease, whereby a tenacious mucus is secreted, is also responsible for this common complaint.

Obesity.—Obesity weakens the abdominal muscles, and thus favors obstipation.

Tumors.—Growths, by their pressure, weaken and obstruct the bowel.

Foreign bodies, either as scybala, enterolitis, or seeds, may cause constipation.

Stricture is a local cause, while atony of the bowel is a very common, general, or systemic cause.

Excessive diuresis and diaphorisis, by withdrawing the fluids from the system, give rise to constipation.

Diet and Water.—A concentrated diet, that is largely deprived of debris, is conducive to constipation, as well as one that is coarse, in which there is an excess of waste; while a change of water, especially to one chalky in character, brings about the same condition.

Pathology.—No characteristic lesions are found as the result of constipation, though dilatation may follow long impaction of the colon. Stercoral ulcers may follow from pressure of scybalous masses.

Symptoms.—These vary in different individuals. In some the general health is but little affected if at all, if the bowels do not move for days and days; while another feels uneasy and nervous if he does not have a stool every twenty-four hours. In my early practice I knew a man of active habits, who enjoyed perfect health, and yet often passed an entire week without stool, saying that he felt absolutely no discomfort.

The symptoms may be divided into local and general.

Local evidence of constipation is found in a sense of fullness and weight in the abdomen, occasionally colicky pains, and a dragging sensation in the rectum. Not infrequently diarrhea alternates with the constipation, where there is more or less flatulency and griping pains. When the stools consist of large, hardened, fecal masses, there is great pain in defecation, leaving the rectum quite painful for hours, and where this continues for a long time, results in painful hemorrhoids.

The general symptoms are legion. The most common are: headache, dizziness, a general sense of languor, bad breath, coated tongue, loss of appetite, palpitation of the heart, cold hands and feet, dark circles beneath the eyes, and melancholy or hypochondriasis.

In women, there are menstrual derangements, owing to pressure against the uterus and its appendages. Not infrequently there is neuralgia, owing to pressure upon visceral and sacral nerves. There is often torpor of the liver, with jaundice, a dry, harsh skin, or one cold and clammy. With these conditions there are dyspeptic symptoms. Pain in the cardiac region, extending to back and under the shoulder-blade, is not uncommon.

Where there is impaction of large masses of fecal matter, the systemic symptoms are so severe that the local condition may be overlooked, and the patient assume a very grave condition. The history of the following cases, which occurred early in my practice, affords a good illustration:

Mrs. O., aged about twenty-five years, mother of one child, complained of various aches and pains, but a gradual enlargement of the abdomen caused her to believe that she was pregnant, and attributed every new symptom that developed, as due to her condition, and made every preparation for a confinement. As time passed, her condition grew worse, and, having passed the time of her expected confinement, she grew anxious, and then alarmed, at her increased and enormous size. At this time, four months after her expected delivery, I was called to the case.

I found the abdomen very much enlarged, though uniform, and the patient quite dropsical; the skin white, inelastic, and doughy, and pitting on pressure. The woman suffered a great deal from abdominal pains. The case being obscure, I called a noted surgeon in counsel. After a careful examination, both digital and by sound, he diagnosed the case as ovarian tumor, and advised an operation. To this the patient asked a few days to decide, and the surgeon left for his home. Forty-eight hours later, I was hurriedly summoned to the house, where I found the patient in great pain. On getting out of bed to urinate, she was seized with a severe cramp, and was delivered of a fetus and after-birth, of about six. months gestation.

The abdomen, however, was but very little reduced in size, and, six or seven days later, I drew a large wooden bucket full of fluid from the abdomen; after which, I could outline a hard, tumorlike substance occupying the left iliac region, and which I diagnosed as fecal matter. I then prescribed one tablespoonful of olive-oil every three hours; had the abdomen massaged with olive-oil every three hours, and an ounce of the oil injected into the bowel every five hours. Within forty-eight hours the tumor mass began to soften and give way, and, with the emptying of the bowel, the dropsy rapidly subsided, and an uneventful convalescence was rapidly terminated.

Diagnosis.—There will be no difficulty about diagnosing simple constipation, and should there be stricture due to malignant growths, the general health would be so impaired that the differential diagnosis could be made. Fecal impaction may be recognized by palpation, percussion, and the use of the rectal tube.

Prognosis.—Unless there is organic stricture or paralysis, the prognosis should be favorable.

Treatment.—Time, patience, regular habits, and persistency in the treatment, are essential to a cure. The constant use of cathartics must be prohibited, and the patient made to understand their harmful effect. To stimulate peristalsis, and at the same time obtain a better circulation in the bowel and abdominal muscles, direct the patient to knead the bowels for ten minutes before rising each morning, drink a glass of cold water, to which is added a drop of nux vomica, and after breakfast make an effort to have stool. If this method is regularly carried out each morning, it will not be long before a marked improvement will be seen.

Impress upon the patient the necessity of going to stool at a regular, stated hour each day, that success depends upon it, and that he or she must never be too busy to carry out one of the most essential parts of the treatment.

For the first few days, in extreme cases, to encourage the patient, fifteen grains of sodium phosphate may be given at bedtime, or a glycerin suppository may be used occasionally; but these should be used only when necessity demands their use.

Well-regulated exercise in the open air should be taken daily by all patients whose occupation necessitates a sedentary life. Where there is fecal accumulation, and where the bowel is lined by mucous feces, like a "teakettle is with lime," high colonic flushing should be used; Have the patient lie in bed, and, with a long tube, introduce into the bowel as much water as the patient can retain; then grasp the abdominal walls, and shake and rub the abdomen, passing the water from side to side, thus thoroughly flushing the bowel, loosening old linings; this will stimulate the bowel as nothing else will. This may be followed by using the double irrigator, allowing several gallons of water to now in and out. Where the bowel has seemingly lost its peristaltic power, galvanism will be found useful. A raw apple, eaten before going to bed each night, has been found helpful in producing a regular habit, or he may eat each morning a fig-ball, composed of the following: Figs and dates, of each one pound; powdered senna two ounces, manna half ounce. Chop the ingredients very fine, and make into sixteen balls.

Fruits and green vegetables should constitute the principal part of the patient's diet. Should there be any rectal irritation, a common cause of constipation, it should be removed. Hemorrhoids, fissures, ulcers, papilla, pockets, etc., should be removed. Sometimes a thorough dilating of the rectum will accomplish much in this direction. After using a rectal speculum in the first dilation, the patient may use a graduated series of porcelain dilators, beginning with the smallest size, and, as the rectum becomes accustomed to its presence, use a larger size. The patient should drink freely of water, but avoid the many saline cathartic waters that are on the market.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.