the pancreas has a more general application than an extract of the
stomach--pepsin. Roberts of Manchester has given full directions for
the method of digesting food by pancreatic extract. Beef, milk, and the
farinacea may be digested, the albuminoid substances being changed into
peptones, the starchy matters into dextrin and sugar, capable of being
absorbed readily with but little or no further alteration in the
digestive tract.[18] Pancreatic emulsion (Dobell) is another method of
giving fat emulsified.
[Footnote 18: Fresh pancreatic extract is made by cutting into small
pieces the pancreas of the pig (which is the best), the ox, or sheep.
The pancreas of the calf yields an extract which acts only on
albuminous substances, but not on starchy matters. The divided pieces
of the pancreas, well freed from fat, are put in a well-corked,
wide-mouthed bottle with four times their weight of dilute alcohol (one
part of rectified spirit to three parts of water). The mixture should
be agitated once daily: at the end of a week the mixture is filtered
through paper until it is clear. A well-made liquid extract of pancreas
is made and sold by Metcalfe of Boston, and a solid extract by
Fairchild Bros. & Foster of New York. No doubt improvements will be
made in the processes of manufacture of these extracts, and better
results will in time be obtained from their use.]
A less successful way of gaining the same object is by administering
the pancreatic extract internally. The difficulty lies in conveying the
extract (the ferment of which is destroyed by the acid gastric juice)
through the stomach in safety. This chemical danger is thought to be
obviated by giving the extract one to two hours after eating with a
{636} protecting guard of an alkali, the bicarbonate of sodium; but the
mechanical difficulty of securing direct transit through the stomach to
the intestine early enough and in quantity enough to digest the
duodenal contents is as great as the chemical obstacle. It is very
doubtful whether this method of use can be of any real service.
In those cases in which the form of indigestion is due to, or is
associated with, a deficient hepatic secretion--a condition indicated
by offensive and light-colored stools and other symptoms--it is
advisable to stimulate the liver to increased secretion. It is probable
that the same remedies which excite a flow of bile do at the same time
stimulate the pancreas. The best of these are euonymin, sanguinarin,
iridin, ipecacuanha, colocynth, jalap, podophyllin, sodium sulphate,
and potassium sulphate. Sodium benzoate, ammonium benzoate, and the
salicylate of sodium are also powerful hepatic stimulants. As one of
the purposes of the bile is to create the alkaline medium necessary for
pancreatic digestion, the administration of an alkaline[19] solution in
full doses, as in the form of mineral water, when gastric digestion is
finished, may make amends for the lack of bile. A combination of an
antiseptic and the alkali may to some extent supply the deficiency
still better, as the bile is the antiseptic of the intestinal canal.
[Footnote 19: The waters of Ems, Vichy (Grande Ville or Hôpital
Springs), Vals, or Bilin may be used for this purpose.]
Atony of the intestinal wall leads to flatulence, colics, and
constipation, and would be a cause of indigestion if none other
existed. It is to be treated by the general rules already given, by
electrical stimulation of the abdominal muscles with the faradic
current, or by the effort to stimulate the intestinal wall more
effectively with the galvanic current. Strychnia in small doses should
be given for some time. In women of relaxed muscular fibre with
enlarged abdomens an elastic belt may be worn with advantage.
After the special aids to the parts concerned in digestion, tonics are
called for to combat the general want of tone and anæmia. The
saccharated iron, the carbonate, potassio-tartrate, lactate,
pyrophosphate, or the ferrum redactum may be given. The syrup of the
iodide of iron is the best form for children. The bitter tonics are
inadvisable except for loss of appetite in cases where the stomach is
not disordered. Quinia is available in a large number of cases in which
malarial influence plays a part. Strychnia is a good general tonic, and
may be prescribed combined with mineral acids, particularly with the
dilute hydrochloric acid.
The special symptoms which call for treatment are flatulence, abdominal
pains, and constipation. All the remedies already described are
directed toward their relief. But sometimes they appear in so
exaggerated a form as to need immediate attention. The many remedies
for colic and tympanitic distension which have the property of
relieving spasm and absorbing gas find application in these conditions.
Constipation is not to be treated by laxatives if it can be avoided.
But the bitter waters, Friedrichshall, Pullna, Hunyadi Jânos, and
Rakoczy, by exciting bile outflow, are sometimes of undoubted curative
value.
The form of dyspepsia called strumous, as it occurs in children of
anæmic appearance with dry skin covered with minute scales, and with
bad breath and light ill-smelling stools, demands a very thorough and
{637} persevering treatment. The advantages of climate must be
sought--seashore in summer with bathing, dry and moderately warm air in
winter. Outdoor life in the sun, with active exercise, is to be had at
the expense of education within-doors. Study is not good for children
of this class except when health is made paramount to it. Cod-liver
oil, either pure, in phosphatic emulsion, or in the pancreatic
emulsion, is a necessity. Malt extract with the hypophosphites is
beneficial. The food must be carefully selected, and the child educated
to a varied diet, including fats. The skin should be anointed daily
with cocoanut oil, olive, cottonseed oil, or cod-liver oil.
{638}
CONSTIPATION.
BY W. W. JOHNSTON, M.D.
SYNONYMS.--Costiveness, Fecal retention, Fecal accumulation, Alvine
obstruction, Obstipation. _Ger._ Koprostase, Stuhlverstopfung,
Hartleibigkeit, Kothstanung. _Fr._ Constipation, Paresse du ventre,
Échauffement. _It._ Constipazione. Older synonyms: Constipatio vel
obstipatio alvi; Alvus tarda, dura, adstricta; Tarda alvi dejectio;
Obstipatio alvarina; Stypsis; Coprostasis (Good).
NATURE AND DEFINITION.--The act of defecation is almost wholly due to
the working of an involuntary mechanism which may be set in play by the
will, and is in part dominated by it, but which is frequently
independent and uncontrolled by volition. Deep inspiration, closure of
the glottis, downward pressure of the diaphragm, and contraction of the
abdominal muscles are accessory, but not essential, to the expulsion of
feces from the rectum. In certain persons, and occasionally in all
persons, especially in diseases where the fecal mass is in a semi-fluid
or fluid form, the strongest effort of the will cannot resist the
expulsive contractions of the rectal muscle. The sphincter is kept in a
state of tonic contraction by a nervous centre situated in the lumbar
portion of the spinal cord. The fecal mass, supported by the bladder
and the rectum, does not at first touch the sphincter; the rectum is
usually empty; but when the column has been well driven into the rectum
peristaltic action is excited in the rectal walls and the sphincter is
firmly pressed upon. The lumbar sphincter centre is now inhibited, and
the ring of muscle opens, the accessory and voluntary muscles contract,
and the expulsive act is completed. In the well-ordered and healthy
individual the rectal walls and the sphincter do not receive the
maximum of irritation from pressure of the advancing column but once in
twenty-four hours. The habit of having one movement in each day is, it
may be believed, in accordance with the natural and physiological
demand, although both the number and the hours of evacuating are fixed
to a great extent by education. The habit once established, the
mechanism of expulsion recurs at the same hour and entirely without the
direction of the will. If the desire be resisted, it will be most apt
not to return until the same hour on the next day.
Defecation depends for its normal character upon the healthy
functioning of the organism, but especially upon the normal processes
of digestion. The character of the rectal contents as to composition
and consistence, and the time of the arrival of the mass at the
sphincter, are {639} regulated by the taking of food at stated hours
and by its normal digestion and absorption. Unaltered or partly-changed
remains of the ingesta pass down the bowel, mingling with the secretion
from the intestinal glands and with mucus and epithelium. As this mass
passes into and through the colon, being propelled by regular
peristaltic waves, it acquires odor from the development of a substance
which is a final product of the putrefaction of albumen.[1] Gradually
the more fluid elements are absorbed, and in the descending colon a
less fluid or semi-solid consistence of the feces is reached. A healthy
digestion and assimilation, with active and regular contractile
movements of the muscular walls of the small and large intestines, are
essential to normal defecation.
[Footnote 1: Ewald, _Lectures on Digestion_, New York, 1881, p. 106.]
Constipation may be defined to be that condition in which there is a
prolonged retention of the feces or in which they are habitually
expelled with difficulty or in insufficient quantity.[2] While there
are individual peculiarities due to habit or nature, the custom with
most persons of having one movement in the twenty-four hours would
cause any longer retention of the rectal contents to be considered
constipation. The limits between health and disease are not well
defined, and a failure to evacuate the bowels for several days need not
be considered pathological nor require medical interference. In persons
otherwise in good health such an occurrence due to neglect, change of
habit or diet, as in travelling, would cause no interruption to health
or comfort. Nature brings relief sooner or later and re-establishes
order and regularity. In many cases constipation is a primary disease
and the cause of many secondary disturbances, but it is often the
effect or the symptom of various acute and chronic diseases. It may be
acute or chronic.
[Footnote 2: Cases of constipation due to mechanical obstruction from
changes in the wall of the intestine or to exterior pressure will not
be considered in this article.]
In long-continued constipation the intestinal contents are so retarded
in their progression along the canal that they undergo a too early and
too complete absorption of their fluid portion. In time there are an
accumulation and impaction of dry fecal masses in the rectum, sigmoid
flexure, descending transverse colon, or cæcum. An obstacle is thus
created which may ultimately close the tube entirely and cause
intestinal obstruction.
ETIOLOGY.--1. Constipation occurs most frequently in advanced life. It
is the effect of loss of peristaltic force and of a diminution of
sensibility in the lower bowel, and is associated with general
functional inactivity and with muscular degeneration and obesity.
Infants are more subject to constipation than children of one year and
over. In many instances this is due to artificial feeding with cow's
milk, condensed milk, and the patent foods so largely used, or with any
diet unsuited to the digestive organs. Imperfect digestion of casein or
other food, the filling of the bowel with a dry mass difficult to
propel, and the consequent catarrhal state of the mucous membrane, are
causes of both constipation and diarrhoea. Feeble, delicate children
with imperfect muscular development, and children born rachitic,
scrofulous, or syphilitic, are generally constipated.
2. Women are prone to constipation much more than men. False modesty,
which imposes restraint upon young girls, and their ignorance {640} of
the necessity of regularity, their habits of indoor life, and avoidance
of exercise, are largely the causes of this. But the anatomical
structure and physiological life of the woman offer another
explanation. At every menstrual period the uterus enlarges and
exercises a greater compression upon the rectum. A tender and enlarged
ovary (and at the menstrual epoch the ovary is always tender and
enlarged) exercises an inhibiting action upon the muscles which bring
the feces in contact with it in their downward passage. In the married
woman recurring pregnancies lead to the habit of constipation from the
long-continued pressure upon the colon, sigmoid flexure, and rectum,
from the extreme stretching of the abdominal muscles, and from the
paralyzing effect of compression during labor. The relaxed condition of
the pelvic and abdominal organs after labor offers no resistance to the
distension of the rectum and sigmoid flexure. The cessation of the
catamenia is accompanied with constipation, nervousness, and a feeling
of ill-defined apprehension when the bowels are moved, or abdominal
pains deter many persons, chiefly women, from habits of regularity. All
uterine and ovarian derangements by mechanical or reflex means bring
about the same result. Chlorosis and anæmia in girls are almost
invariably associated with constipation.
3. Hereditary influence shows itself very markedly in the tendency to
constipation which is seen in many members of the same family. This is
probably more often apparent than real, and is the result of neglect of
the proper attention to the wants of children and of the perpetuation
of vicious habits of taking purgatives.
4. The habits of life and the occupation of the individual have much to
do with the causation of constipation. Those who lead active outdoor
lives are generally regular in their daily movements, but persons of
sedentary pursuits or who work in constrained attitudes--lawyers,
clerks, tailors, shoemakers, and seamstresses--are predisposed to
constipation. Intellectual work, not only from the muscular inactivity
which it entails, but from the diversion of energy to the
nerve-centres, develops the constipated habit as well as indigestion.
Men who are overworked in business, employés in banks, government
offices, shops, etc., bring on the habit from the hurry incident to
their occupations. Luxurious and enervating habits of life, over-eating
and sloth, with the over-indulgence in alcohol and tobacco, have the
same effect. All the influences which deteriorate health, such as bad
ventilation and over-heating of rooms, foul air, want of cleanliness of
the person, indigestible food, imperfect mastication, tight-lacing in
women, compression of the abdominal organs in men, can be said to share
in bringing it about. Servants, especially women, are constipated more
frequently than their masters. This is due to ignorance and neglect,
and sometimes to excessive tea-drinking and irregularity in eating.
5. Neglect to establish or continue a habit of daily regularity in
defecation leads to the accumulation in the rectum of masses of feces.
Resisting the desire to empty the bowel interrupts the necessary reflex
acts, and finally the muscular excitability and response to the
presence of feces are entirely wanting. The continued contact of fecal
matter with the mucous membrane wears out its susceptibility; the
over-distension of the rectum enfeebles the power of its muscular wall,
as is the case when all hollow muscular organs--stomach, heart,
bladder--are overstretched. Thus a {641} neglect to answer the demand
for a daily movement and the failure to completely empty the rectum
will gradually develop constipation in a person who has before been
perfectly well regulated. In childhood failure to teach and to insist
upon good habits is the cause of much of the trouble of after-life.
6. Acute and chronic diseases of the brain and spinal cord bring about
constipation. Meningitis, encephalitis, and myelitis, senile dementia
and softening, have it as a symptom at some time or other. In
encephalitis and myelitis there is an interruption of motor
nerve-currents. In meningitis and tetanus the muscular walls of the
bowel and the abdominal muscles are in a state of tonic contraction.
7. The use of aperients is an important agent in developing the
constipated habit by over-stimulating and wearing out muscular
activity. The idea that a daily movement is a necessity, and that an
occasional purgative is useful in relieving the system of morbid matter
which would otherwise induce disease, is the chief source of this
hurtful custom. The traditional meaning attached to the term
biliousness implied the resort to cathartics for its relief, and it is
much to be regretted that with our more advanced knowledge the effort
should be made to revive the use of this term, which was wellnigh
abandoned. More ignorance and erroneous treatment has hung upon the
theory of biliousness than upon any other doctrine of medicine within
the past thirty years: it is well for physicians to condemn it and to
resist its reintroduction into scientific phraseology.[3] If the term
bilious as applied to diseases were abandoned, much good would come of
it. The general use of purgative mineral waters has added to this evil.
Among the better classes these waters play the same part as the liver
regulators and vegetable pills do among laborers and servant-maids.
Both gratify the innate love for self-medication by a resort to
cathartics for the slightest ailment. At first the injurious effects
are not apparent, but in time the reflex function is not brought into
activity except by artificial aids. The intestinal and rectal muscles
must be whipped into action, their normal contractile power being lost.
[Footnote 3: For an excellent and dispassionate statement of the
reasons for abandoning the theory of the influences of bile as a cause
of disease, and the use of the term bilious, consult _The Bile,
Jaundice, and Bilious Diseases_, by J. Wickham Legg, chaps. viii. and
xxix. The Hippocratic and Galenical belief has been transmitted with
but little alteration through Stoll, Andrie, Abernethy, and Copland to
the writers of to-day on biliousness.]
8. Certain vegetable and mineral substances taken either intentionally
or by accident constipate the bowels. Chief among these stand opium and
its preparations. All opium-eaters are constipated. Lead which is
accidentally taken into the system by workers in metals, painters, etc.
invariably produces obstinate constipation. The use of tobacco in
excess has the effect of deranging digestion and causing constipation
in many persons, but this result is occasional only.
9. Chronic diseases of the lungs and heart, by enfeebling the muscular
movements which take part in defecation, as well as by the general
feebleness and the chronic intestinal catarrh and indigestion which
they create, are causes of constipation. Chronic diseases of the liver,
especially cirrhosis, are also causes. Constipation accompanies
obesity, for in very fat persons the abdominal walls have but little
power of contraction; the {642} muscle-layer is thin and flaccid. There
is also in such persons in advanced life an accumulation of fat in the
mesentery and around the colon. The muscle of the bowel is in a state
of fatty degeneration, and atony and dilatation of the gut follow.
10. Painful affections about the rectum and anus deter persons from
yielding to the desire for defecation. Fissure of the anus is the
principal one of these, but fistula, hemorrhoids, and local eczema have
a similar influence. A simple rigidity or spasmodic stricture of the
anal sphincter creates constipation.[4]
[Footnote 4: Kunemann, _De la Constipation compliqués de Contraction du
Sphincter anal, et de son Traitement par la Dilatation de l'Anus_,
Paris, 1851.]
11. Constipation is a symptom in chronic cachexiæ and wasting diseases,
in the convalescence of acute exhausting illness, as typhoid fever and
pneumonia, or in persons bedridden from any cause. Defective nutrition
and degeneration of the muscle-fibre of the intestine explain these
cases. In some of them, with improved nutrition, regeneration takes
place with a return of contractility.
12. Disorders of the digestive system have constipation as a
consequence and a symptom. The reflex sympathy between the movements of
the stomach and of the intestines brings this about in gastric
diseases.[5] It occurs in gastric cancer and ulcer, in acute and
chronic gastritis, in dilatation of the stomach, and in pyloric
stricture. The small amount of ingesta entering the duodenum in these
diseases diminishes the bulk of fecal matter. In acute intestinal
catarrh diarrhoea is the rule, but the bowels may be constipated in
intense inflammation and ulceration of the mucous membrane, as is often
the case in typhoid fever. In chronic intestinal catarrh constipation
is more common in the mild forms than diarrhoea. The thickening and
irritation of the mucous membrane lead to a diminution of reflex
excitability and loss of elasticity and contractility in the muscular
coat. Hence, except in cases where the inflammation is low down or
where ulcers have formed, constipation is a more frequent symptom than
diarrhoea. The alteration in the quantity and character of the
intestinal secretions in chronic catarrh is stated to be an important
element. This is to some extent true. Mucus, which is the chief product
of this condition, leads to indigestion and fermentation of the
intestinal contents and to increased irritation of the mucous membrane.
The evolved gas distends the bowel and weakens its contractile power.
The fecal mass when it reaches the rectum has an excess of mucus within
it or around it which makes its expulsion more difficult. But the
diminution or absence of bile does not constipate. In simple jaundice
diarrhoea is not uncommon, and an excess of bile does not of necessity
cause diarrhoea.[6]
[Footnote 5: Leube, in _Ziemssen's Cyclopædia_, vol. vii. p. 211.]
[Footnote 6: Legg, _op. cit._, p. 271.]
The effects of the modifications of the pancreatic secretion are not
well known. Pancreatitis is attended by constipation. Fatty diarrhoea
is believed to follow occlusion of the pancreatic duct by pancreatic
calculi and chronic catarrh of the duct. Peristalsis is lost in
peritonitis from the muscular coat being infiltrated with serum and
paralyzed, but tuberculous peritonitis is frequently accompanied by
diarrhoea.
13. Loss of fluids by abundant perspiration, by diuresis, diabetes and
lactation, increases the dryness of the bowel contents and hinders free
{643} evacuations. This is observed as a result of the arrival in a
tropical climate and in very hot weather in any climate. The profuse
sweats accompanying phthisis, acute rheumatism, intermittent fever, and
unusual exercise cause constipation. Another explanation which applies
to this has been offered by Good and Eberle, who ascribe constipation
to the excessive action of the absorbents in the small intestine, by
which the fluid portion is too rapidly and too thoroughly removed.[7]
Exercise by promoting activity of the functions in general may induce
constipation in this way. In spermatorrhoea the stools are infrequent.
An insufficient amount of water taken with food is another cause.
[Footnote 7: Dick, _Braithwaite's Retrospect_, xvii. p. 152.]