beef--leaves a small residuum to be propelled along the intestine, and
therefore in one sense is constipating. Insufficient food acts in the
same way. An indigestible diet in excess, especially vegetable food, a
large part of which is insoluble, constipates by filling the bowel with
matter which cannot be got rid of, and chronic catarrh results. The
stones and seeds of fruits, as cherry- and plum-stones, raspberry- and
currant-seeds, husks of corn and oats, produce acute or chronic
constipation with serious symptoms. Intestinal worms (generally
lumbricoids) when in large numbers cause obstruction of the bowel;[8]
and various foreign substances taken by caprice or to take the place of
food have produced the same result: among these stick cinnamon,[9]
sawdust,[10] and clay (among the clay-eaters of the South) have been
mentioned. Magnesia, insoluble pills, and other medicines sometimes
form concretions in the bowel. Enteroliths and accidental concretions
form in the intestinal canal and are sources of obstruction. Any
foreign body is a nucleus around which concentric layers of phosphate
of lime are deposited, and thus a hard calculus is formed. Gall-stones
may pass into the canal and there accumulate in such numbers as to
interfere with the passage of the fecal matter.
[Footnote 8: Copland, _Medical Repository_, vol. xvii. p. 243.]
[Footnote 9: Ware, _Boston Med. and Surgical Journal_, 1858, vol.
lviii. p. 501.]
[Footnote 10: Bonney, _ibid._, 1859, vol. lix. p. 39.]
PATHOLOGICAL ANATOMY.--In cases where constipation has lasted many
years no alteration of the parts involved may be found. When lesions do
occur the pathological anatomy includes changes in the position,[11]
calibre, and in the walls and contents of the intestines. The most
common displacement is that of the transverse colon, which is depressed
in its centre; the acute angle of the descending part may reach as far
down as the hypogastrium. The cæcum sometimes lies in the centre of the
abdomen. Dislocations of the intestines are congenital, due to
anomalies of intra-uterine development, in which case they become
causes of death in newly-born children from obstruction, or if
insufficient to cause death they establish habitual and incurable
constipation; or constipation may bring about displacement by the
greater weight of a portion of the bowel constantly loaded with fecal
matter.
[Footnote 11: Vötsch, _Koprostase_, Erlangen, 1874.]
The sigmoid flexure is usually the seat of the greatest dilatation; its
expansion may be a cause or a consequence of constipation.[12] It may
reach a maximum of distension when it fills the entire abdominal
cavity, compressing all the abdominal organs and pushing the stomach,
liver, {644} and intestines into the thorax. In a case of this kind the
circumference of the dilated part was twenty-seven inches.[13] The
descending colon may be distended with the sigmoid flexure, or the
whole colon may be dilated from the upper part of the rectum to the
cæcum;[14] the same thing happens rarely in the small intestine. In one
case, in which there was an accumulation of feces in the sigmoid
flexure, the large intestine presented itself as two immense cylinders
lying side by side, extending from the epigastrium to the pelvis.[15]
Each was about five and a half inches in diameter, and together they
filled the abdominal cavity. The circumference of the stretched colon
varies from ten to thirty inches. Pouches forming little rounded tumors
are seen on the outer surface of the colon; they are sometimes hernial
protrusions of the mucous membrane through the muscular coat (Wilks and
Moxon), or if large they are dilatations of the pouches of the
colon.[16]
[Footnote 12: Trastour, "De la Dilatation passive de l'Iliaque, et de
ses conséquences," _Journal de Méd. de l'Ouest_, 1878-79, tome xii. p.
165.]
[Footnote 13: Dupleix, _Le Progrès médicale_, Paris, 1877, tome v. p.
953.]
[Footnote 14: Peacock, "Fatal Constipation, with Excessive Dilatation
of the Colon," _Tr. Path. Soc. London_, vol. xxiii. p. 104.]
[Footnote 15: Lewitt, _Chicago Med. Journ._, vol. xxiv., 1867, p. 359.]
[Footnote 16: Gay, "Sacculated Colon, Prolonged Constipation," _Tr.
Path. Soc. London_, vol. v. p. 174.]
The colon is sometimes much lengthened. But little weight can be
attached to this anomaly, as there is a difference in the length of the
colon in different nations and individuals, depending upon the
character of the food, being longer in those who eat largely of
vegetable food.[17]
[Footnote 17: _Ziemssen's Cyclopædia_, vol. vii. p. 606.]
The mucous membrane is normal or hyperæmic, or is in various stages of
chronic catarrh. Proctitis may exist with follicular ulcers; ulcers
form in the cæcum, sigmoid flexure, and in the bends of the colon;
perforations and peritonitis rarely occur. Chronic peritonitis has
resulted from the stretching of the bowel from retained and hardened
feces; adhesions may form which ultimately cause death by obstructing
the canal. The walls of the intestines are in long-standing cases much
thinned. There are many reasons to believe that fatty degeneration of
the smooth muscular fibre takes place, in consequence of which it loses
its contractile power and atrophies. This lesion is most common in
advanced life, and accompanies fatty accumulation and degeneration
elsewhere. Its results would be constipation, distension of the bowel
with gas, and sometimes symptoms of intestinal obstruction.[18] A
thinned and dilated bowel may easily be lacerated under unusual
stimulation, as from a purgative. In a case recently seen by the writer
such an accident, rupture of the colon and death from peritonitis,
occurred from the effects of an active purge taken to bring on
abortion. Hypertrophy of the wall, especially of the muscular coat,
coexists with dilatation, and is most common in the upper part of the
rectum and sigmoid flexure. It is caused by overwork in expelling fecal
accumulations. The walls never become as much thickened as in
constipation from organic stricture.
[Footnote 18: Cases are recorded of death with symptoms of intestinal
obstruction in which no lesion was found beyond a dilated colon; as,
for example, in _British Medical Journal_, April, 1879, p. 621.]
Collections of fecal matter may be found in any portion of the colon,
but more frequently in the rectum, sigmoid flexure, descending or {645}
transverse colon, or cæcum. They lie within the intestinal tube, partly
or wholly occluding it, or within lateral pouches, forming tumors which
are sometimes quite large. In this last form there is no obstacle to
the free passage of feces along the canal. Fecal accumulations occur as
small round, oval, or irregularly-shaped lumps (scybalæ), and are often
covered with layers of transparent semi-fluid mucus, puriform mucus, or
mucus in filaments. The small concretions vary in density; they may be
so hard as to resist the knife, and may be mistaken for gall-stones;
larger masses, semi-solid or solid, are most commonly seen in the
rectum and sigmoid flexure. Here the collection may reach an immense
size. In one case fifteen quarts of semi-solid, greenish-colored fecal
matter were removed at the autopsy.[19] In two other cases the weight
of the feces found in the bowel was thirteen and a half[20] and
twenty-six pounds[21] respectively. The whole colon from the anus to
the cæcum may be filled with such a mass, as in a case mentioned by
Bristowe, where the colon "was completely full of semi-solid
olive-green colored feces. The small intestines were also considerably
distended, ... and were filled throughout with semi-fluid olive-green
contents."[22]
[Footnote 19: Peacock, _Tr. Path. Soc. London_, vol. xxiii. p. 104.]
[Footnote 20: Lamazurier, _Archives générales_, Paris, 1824, t. iv. p.
410.]
[Footnote 21: Chelius, _Heidelberg Med. Ann._, 1838, vol. iv. p. 55.]
[Footnote 22: Bristowe, "Diseases of Intestines and Peritoneum,"
_Wood's Library_, New York, 1879, p. 21.]
The color of these collections is black, reddish, deep green, or
yellow. In composition the scybalæ, concretions, and larger masses
consist of fecal matter, with unaltered vegetable fibre; they may be
composed partly of skins of grapes, cherry-stones, biliary calculi,
hair, woody fibre, magnesia, or other foreign substances. Where fecal
concretions long remain in the intestine they acquire a hardness like
stone, and can with the microscope only be distinguished from mineral
matter.[23] Hemorrhoidal tumors, anal fissures, perirectal abscesses,
fistulæ communicating externally or with the gut, are found in
connection with constipation. Abscess of the iliac fossa has been
observed in the same relationship.[24]
[Footnote 23: A remarkable case is recorded (_Dictionnaire de
Médecine_, Paris, 1834, t. viii. p. 435) in which an ulcerating cancer
of the fundus of the uterus had opened communication and formed
adhesions with the small intestine, from whence the feces passed into
the uterus and out through the vagina. The large intestine, totally
occluded, contained petrified fecal matter.]
[Footnote 24: Richet, "Abscess of Iliac Fossa," _Revue de Thérapeutique
médico-chirurgicale_, 1876, p. 563.]
SYMPTOMS.--In persons who have a daily movement an occasional
interruption of two to four days may take place without local or
general signs of inconvenience. It is often asserted by patients that
one day's omission induces suffering, and recourse is immediately had
to laxatives. This may be justified sometimes, but in the majority of
cases no actual suffering follows a very rare and short
constipation.[25] If, however, symptoms do occur after a constipation
of one to three days, there is a sense of fulness and heat about the
rectum which is greater after stool; when the bowels are moved, it is
with effort (provided that no enema or purgative has been taken), and
the bulk of the expelled mass is much greater {646} than usual, being
moulded and hardened from its longer retention in the rectum. The
margins of the anus are tender, and the unsatisfied feeling after stool
is due to distension of the hemorrhoidal veins and oedema of the
tissues around them--a condition which ends in painful or bleeding
hemorrhoids. There are signs of impaired digestion, loss of appetite, a
coated tongue, oppression after eating and flatulence, and distension
of the abdomen. Headache is apt to be present, with flushing of the
face and general discomfort or irritability of temper. These phenomena
may all disappear within two or three days by a spontaneous stool or by
the use of a purgative.
[Footnote 25: Some interesting remarks in connection with the idea that
constipation is not necessarily hurtful, and is in some cases
beneficial, may be found in a pamphlet by C. I. Harris, _Is our
Physiology of the Large Intestine correct, and is Constipation in
certain cases as Injurious as is supposed?_ London, 1878.]
Acute symptoms of a violent nature are sometimes developed in persons
who have been constipated a long or short time, in consequence of
attempts at purgation or from the accumulation of indigestible food.
Violent paroxysmal pains in the abdomen and efforts at stool are soon
followed by symptoms of intestinal obstruction and serious collapse.
Quick relief follows a free movement from the bowels obtained by an
enema, or if not so relieved the case may terminate fatally.
A frequent recurrence of fecal retention from the causes mentioned will
in time develop the constipated habit. Distension of the rectum
increases its capacity and destroys its sensibility and expulsive
power. The colon above the point of stoppage is distended with gas and
weakened. The bowels are rarely moved spontaneously, and finally are
never emptied without artificial aid. The literature of medicine
contains many extraordinary records of prolonged fecal retention,
ranging from a few weeks to many months.[26]
[Footnote 26: _Am. Journ. Med. Sci._, Philada., 1846, p. 260 (three
months and twenty-two days); Renaudin, _Dict. des Sci. méd._, t. vi. p.
257 (four months); Strong, _Am. Journ. Med. Sci._, Oct., 1874, p. 440
(eight months and sixteen days); Valentin, _Bull. des Sci. méd._, t. x.
p. 74 (nine months); Staniland, _London Med. Gaz._, vol. xi. p. 245
(seven months); _Dublin Hosp. Reports_, vol. iv. p. 303 (eight months);
Inman, _Half-Yearly Abst. Med. Sci._, vol. xxxi. p. 275 (two years);
Devilliers, _Journ. de Méd._, 1756, t. iv. p. 257 (two years); J.
Chalmers, _Med. Gaz._, London, 1843, vol. xxi. p. 20 (three years);
_Philada. Med. Museum_, 1805, vol. i. p. 304 (fourteen years).]
The evacuations in chronic constipation are harder and more dry than
they should be; they are passed in masses of various sizes, and in
color are brown, black, dark-green, or yellow. Sometimes a coating of
mucus is on the outside, and sometimes streaks of blood, or there is an
intimate admixture of mucus, giving a slimy, gelatinous appearance to
the mass. Semi-digested food, as partly-altered milk, meat, or
vegetable matter, is seen, and quite frequently there is an
intercurrent diarrhoea which alternates with costiveness.
The local symptoms about the pelvis and anal opening and in the lower
extremities come from the pressure of accumulations of feces. Thus,
compression of the iliac veins delays circulation in the lower
extremities; cold feet or oedema of the feet and ankles and varicose
veins follow. If the pressure is on the ilio-hypogastric and
ilio-inguinal nerves, there are neuralgic pains in the groin and over
the crest of the ilium. The sciatic and crural nerves may be the seats
of pain. Varicocele is the effect of weight upon the spermatic veins.
Erections and seminal emissions in men follow pressure on the pubic
veins and prostatic portion of the urethra. Retention of urine also may
come from the latter cause. If the kidneys and ureters are compressed
by fecal tumors in the descending or transverse {647} colon, nephritic
pain, albuminuria, or retraction of the testicle, with delay in the
escape of urine, may happen. Icterus and its consequences are owing to
pressure on the common bile-duct; the liver and other organs may be
displaced and the aortic circulation obstructed by fecal compression.
In women the retention of fecal matter in the rectum is the source of
special symptoms; it contributes largely to the occurrence of cervical
anti-flexion in the soft, pliable, growing uterus of girlhood (Thomas),
and unites with retroversion in women who have borne children to
produce great suffering.
An unnatural state of the digestive system, as a cause or result, is
the invariable accompaniment of chronic constipation. The appetite is
wanting; the tongue is coated, and may be pale, soft, and indented by
the teeth. Distress follows eating; the abdomen is distended with gas
and is hard; all the evidences of gastric or intestinal indigestion may
be found. Nutrition is imperfect, as is shown in loss of flesh and in
the signs of functional disorder to be next described.
The nervous system is soon deranged; sleep is unrefreshing, restless,
and disturbed by dreams. There are headache and mental and physical
indolence. The patient speaks of being giddy, faint, and nervous.
Disturbance of vision (muscæ volitantes), of hearing (tinnitus aurium),
and alarming attacks of dyspnoea and cardialgia may occur.[27]
Heart-palpitations and profuse perspirations are the effect of
excitement or effort of any kind. Chilliness or violent chills can be
traced to this cause also. In women hysteria, disturbed menses, anæmia,
and chlorosis accompany constipation.
[Footnote 27: C. C. Melhose, _Hufeland's Journal_, 1841, xcii., Stuch
iv. p. 105.]
Nervous symptoms are very common in the young, and it is doubtful
whether they are consequences of constipation or whether they form a
part of a general state of malnutrition and anæmia. Hypochondria is
undoubtedly closely connected with the constipated habit, and the
failure to secure a daily movement becomes the subject of unceasing
thought and anxiety. Hallucinations and sudden loss of consciousness,
aphasia,[28] and delirium, have been found to depend upon fecal
accumulation.[29] The absorption of fluids and gases from
too-long-retained and decomposing feces may explain such cases. The
nerve-centres soon show the effect of the supply of altered or
contaminated blood.[30] It is probable that the marked nervous symptoms
are more due to this cause than to reflex influences.
[Footnote 28: Mattei, "Aphasia cured by relieving Constipation," _Bull.
de l'Acad. de Méd._, Paris, t. xxx., 1864-65, p. 870.]
[Footnote 29: Pulitzer, _Wien. med. Presse_, 1866, x. p. 439. Case.--A
man æt. 42, with sleeplessness, hypochondriasis, hallucinations, and
one attack of sudden loss of consciousness; symptoms relieved by
removing a large quantity of fetid fecal matter from bowels. Also
Dujardin-Beaumetz, serious nervous symptoms due to constipation
(_Bullétin de Thérap._, Paris, t. 89, 1875, p. 179).]
[Footnote 30: Bell, _Lancet_, London, 1880, i. 243-283.]
A coincidence exists between dislocation of the colon and various
states of mental disturbance. Ten cases of suicide were seen by Vötsch
in which there were displacements of the colon. Laudenberger of
Stuttgart found that in ninety-four autopsies of insane persons there
were anomalies of position of the transverse colon in one-seventh of
the number (Vötsch).
Fever is not infrequently due to constipation. During the course of
typhoid and other fevers an unusual elevation of temperature is often
{648} traced to a neglect to have the bowels emptied. But very high
temperature sometimes depends upon constipation alone, and is at once
reduced by removing the cause. This may occur in the course of chronic
diseases or in health, especially in children.[31] The temperature
rises from normal to 104° F., and even higher, and immediately drops to
normal when the bowels are moved. When a sudden rise in temperature
comes with acute constipation, the influence must be a reflected one
from the mucous surface to the heat-centre.
[Footnote 31: F. Barnes, "On the Pyrexial Effects of Constipation,"
_Med. Press and Circular_, 1879, N. S. xxviii. p. 477. Also, C. H.
Jones, _Lancet_, London, 1879, ii. p. 229--a case in which there was a
temperature of 104.1°, pulse 180, and delirium due to scybalæ in bowel;
Cabot and Warren, "High Temperature from Constipation," _Boston Med.
and Surg. Journ._, 1880, ciii. p. 1571.]
The urine is dark-colored and scanty, loaded often with urates, or it
may be limpid and of a very low specific gravity. The escape from the
bladder and through the ureters may be obstructed by compression, as
already mentioned. Suppression of urine has occurred, and been relieved
by removing large fecal collections.[32] In women catamenial
irregularity and dysuria are generally associated with constipation.
Disturbances in pelvic circulation and local pressure of a distended
rectum explain these conditions.
[Footnote 32: Barnwell, _Cincin. Med. News_, 1875, vol. viii. p.
353--female æt. 45. Had no movement for five days; suffered with
tympanites; severe pain in right iliac region, with persistent
vomiting; tumor in same region; complete suppression of urine. At the
end fifth day passed large quantity of apple-peelings and fecal matter.
Return of flow of urine; passed two gallons in ten hours.]
The skin is often parched, sallow, and is sometimes covered with
eruptions, as acne, psoriasis, eczema, erythema, or prurigo. Injuries,
wounds, and cracks of the skin heal slowly.
RESULTS AND COMPLICATIONS.--The lateral pouches of the colon, most
commonly at the sigmoid flexure, become distended, and deeper pouches
are formed, where fecal matter is retained.[33] This need not interfere
with the regular daily movements. Fecal tumors are thus formed, the
nature of which is often not recognized. The colon may be distended so
as to fill a large part of the abdomen. The pressure of hardened feces
brings about ulceration of the mucous membrane, perforation and
extravasation of the contents into the abdominal cavity, with fatal
peritonitis. Abscesses in the perirectal tissues, with fistulæ,[34]
anal fissures, hemorrhoids, prolapse of the rectum, varices of the
prostate gland and bladder, owe their origin to fecal collections,
especially in advanced life.
[Footnote 33: Long, _Med. Times and Gazette_, 1856, vol. ii. p. 286.]
[Footnote 34: Bannerot, C., _Du Phlegmon pelvi-rectal inférieure et de
la Fistule de l'Anus consécutive causées par la Constipation_, Paris,
1880.]
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]
[Footnote 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.]
{649} 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]
[Footnote 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]
[Footnote 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.