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 {650}
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]
[Footnote 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 tumors[40] 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.
[Footnote 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]
[Footnote 41: Jas. Y. Simpson, _Med. Times and Gazette_, London, 1859,
vol. ii. p. 549.]
[Footnote 42: Thomas Bryant, _Med. Times and Gazette_, London, vol. i.,
1872, p. 303.]
[Footnote 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]
[Footnote 44: H. R. Storer, _Gynæcological Journ._, 1869, vol. i. p.
80.]
The history of each individual case, a full knowledge of etiological
factors, and a careful physical examination will in most instances lead
to a proper diagnosis.
PROGNOSIS.--The result of treatment depends upon the age. Although in
infancy constipation is very common, cure is the usual result where a
mixed diet begins to be taken in childhood. At from one to fourteen
years of age regular movements can usually be secured, unless there is
a radical defect in the organization of the child. In young girls at
puberty and after, if constipation once is established it is apt to
become inveterate, associated as it is with imperfect development and
with uterine displacements. In middle life in men the result depends
upon the cause and upon attention to the physician's counsel. If
intestinal catarrh or atony is the cause, a persistent subordination of
the life of the individual to the object in view will generally end in
cure. In women who have borne {651} children the hope of relief depends
upon the duration of the malady before treatment. It is a dispiriting
task to attack a constipation of many years' standing in women with
relaxed abdomens, uterine prolapsus or retroversion, and general
debility. In old age the causes are generally such as cannot be
removed. The bowels can be moved when the occasions demand, but there
is very little expectation of establishing a spontaneous habit of
regular fecal movements.
At every age and from whatever cause perseverance and hope on the part
of the patient and doctor are the chief elements of success. In
neglected cases the worst results may happen: dilatation of the colon,
ulceration, fecal impaction and obstruction, perforation; or in milder
cases chronic indigestion, hypochondria, etc.
TREATMENT.--The physician can render great service by giving to parents
advice which will prevent constipation in children. He should insist
upon the importance of habits of regularity in defecation. At the
period of puberty in young girls this is of even greater moment, and no
opportunity should be lost for pointing out the danger of neglect. As a
prophylactic measure in adults counsel should be given suited to the
occupation. To persons leading sedentary lives the necessity of
exercise ought to be made clear. In the trades little can be done, but
in the case of literary men and those who read or write for many hours
prevention is easier than cure. Daily exercise, walking or riding,
frequent bathing with active sponging and friction of the surface,
especially over the abdomen, will be of much service. Avoiding
constrained positions where pressure is brought to bear upon the
abdomen, as in bending forward to write, is quite an important item.
Among ignorant people advice of this kind is rarely attended to, but
even here the doctrine of regularity should never cease to be preached.
Active business-men, especially young men, need emphatic teaching. They
cannot plead ignorance for the habitual and persistent neglect of the
simplest rules of health of which they are in this country so often
guilty. The symptoms of indigestion which are precursors of
constipation should receive due attention, and a mode of life and
dietary suited to a complete digestion of the food will favor the
timely and proper expulsion of waste matter.
Acute constipation in a previously healthy person, lasting for one to
three days, does better without interference. No harm attends temporary
inaction of the bowel, and if a spontaneous stool takes place at the
end of this time it is a sign of a healthful and vigorous condition.
After this the normal regularity is restored. The habitual clearing out
of the bowel by a purgative pill or dose of mineral water whenever such
a state of matters occurs creates the necessity for the interference.
The man who never lets himself go over a day without an action is
miserable if he misses his purgative and its effects.
In the onset of acute diseases the custom of giving a preliminary
purgative is generally unnecessary, often injurious. It disturbs the
rest which such cases need; it produces exhaustion in some diseases, as
pneumonia, pleurisy, and rheumatism; it irritates the mucous membrane
when irritation involves danger, as in intestinal catarrh and typhoid
fever.
When it is desirable to empty the bowel in acute constipation a
warm-water enema for adults and children is the best means. When a
laxative is necessary in case of a failure of the enema, one mild in
its operation {652} should be chosen--a compound rhubarb pill, one to
five grains of calomel, a teaspoonful of Rochelle salts, or half a
bottle to a bottle of the solution of the citrate of magnesia or the
tartro-citrate of sodium. For children calomel, in doses of one-third
of a grain to one grain, is one of the most certain and least
objectionable. One grain of powdered rhubarb can be added to this for a
more active effect.
Under such circumstances as a blocking up of the bowel with a mass of
partially digested or undigested food, fruit-stones, skins, or other
foreign bodies, where the symptoms are violent pain, tympanites, and
vomiting, the best method is to give large enemata of warm water
through a long rectal tube passed as high up as possible, and to
administer calomel in doses of one to three grains, repeated every two
to three hours until the bowels are moved. Cold can be applied to the
abdomen to diminish tympanites and prevent inflammation. Should the
constipation not yield and the pain, vomiting, and tympanites augment,
the case will then be considered one of intestinal obstruction, and be
treated as such.
When called upon to treat chronic constipation, the physician should
remember that it is not the symptom, but its causes, to which he should
direct attention. Constipation is so often a symptom, a complication,
of other diseased states that its management is a matter of secondary
importance. Moreover, its causes are so peculiar to the individual and
depend upon so many variable habits of life that each case asks for
special study. The cure is only to be found by learning the particular
cause--the habit of neglect, hurried eating, the use of aperients,
uterine displacement, or any of the many causes enumerated.
The digestion and all that concerns it is of primary importance, and to
it attention should be at once directed. The stomach and intestinal
digestion should be examined separately, and the relative power to
digest different articles of food determined. A diet, then, should be
selected, not with a view to correcting the constipation, but as to its
suitability to the digestive capacity of the patient. No system of diet
can be fixed upon as suited to every case: the aim is to secure normal
digestion and absorption and normal peristalsis. Many trials may have
to be made before a proper dietary can be chosen. When there is
indigestion of fats and malnutrition, with pale offensive stools
containing much mucus, an exclusive nitrogenous and easily digestible
diet--such as is advised in the article on INTESTINAL
INDIGESTION--should be prescribed. In constipation connected with
membranous enteritis a similar system of diet is proper. The drugs
given should be those which aid intestinal digestion, and reference
must be made again to this subject, already treated of. Many cases of
constipation can only be cured by this treatment; the routine treatment
by purgatives and a diet of vegetables and fruits would aggravate and
not relieve. A course of exclusive milk or skim-milk diet, if
persevered in for some weeks, will cure cases of constipation of this
kind without the use of laxatives. Of course a purgative must sometimes
be given if enemata fail, but the least irritating one should be
selected.
The mineral waters best suited to constipation depending upon
intestinal catarrh are in this country those of the Rockbridge Alum
Springs and Capon Springs (Va.), the California Seltzer Springs, and
the milder {653} waters of Saratoga. The most suitable from Europe are
the waters of Apollinaris, Vichy, Buda, Vals, Ems, Salzbrunn, Selters,
Mt. Doré, and Kissengen. The warm baths of Virginia (Warm Springs, Hot
Springs) are useful in increasing the activity of the skin and in
giving relief to the catarrhal state. A month spent at the Warm
Springs, with a daily bath the natural heat of which is 98°, will work
a complete transformation in the abdominal circulation. This should be
conjoined, of course, with a properly-regulated diet and exercise.
Another month spent at the Rockbridge Alum Springs will complete the
restoration of the bowel to a normal state. It is much to be regretted
that the really valuable mineral springs of Virginia lack so many of
the comforts which the invalid requires. In cases where it is more
convenient a stay at the Arkansas Hot Springs is to be suggested, and
for obstinate cases of intestinal catarrh with sluggish circulation,
obesity, and gouty tendencies these springs are to be preferred. A
season at some of the mineral baths of Europe, as Aix-la-Chapelle,
followed by the strict regimen of the grape cure (as at Bingen,
Durkheim, Vevay, Montreux, or Meran), is a rational mode of treatment
which offers an almost certain prospect of cure.
If the case is one of atony of the colon due to impaction of the rectum
and dilatation of the rectum and colon, without gastric or intestinal
indigestion, a quite different regimen is required. The constitution
and mode of life are the guides to the general plan to be followed.
Sedentary pursuits are to be given up as far as possible. Long
vacations and travel must be insisted on, with active exercise by
walking and riding; also cold bathing or sponging, with brisk friction
of the whole body. Sea-bathing is useful both as an exercise and for
the effect upon the sluggish peripheral circulation, but the slothful
life at the seashore, with over-indulgence in eating and drinking, is a
source of more harm than good. Warm baths, and cold douches to the
abdomen, compresses of cold water or of alcohol, the cold douche to the
spine while in the hot bath, are all beneficial. Massage for women,
children, and feeble persons takes the place of exercise. The kneading
of the muscles over the abdomen can be combined advantageously with an
effort to accelerate the passage of the contents of the colon by
manipulation in the direction of movement.
The interrupted electrical current, used for the purpose of developing
the feeble abdominal muscles, is a source of much advantage.[45] But to
be of service it should be persevered in for months, the patient
himself making the application under the direction of the physician. In
addition, the introduction of one insulated electrode into the rectum,
while the other is in contact with the abdominal muscles or along the
line of the large intestine, has been advised. The Swedish movement
cure may be a useful aid in some cases. The movements exercise the
muscles of expulsion. These are deep inspiration, flexion and extension
of thighs or trunk, twisting the trunk, pressure on the abdomen and
colon, stroking in the direction of fecal movement.
[Footnote 45: S. T. Stern, "Die faradische Behandlung der Obstipation
und der nervosen Enteropathie," _Centralblatt für Newenheil_, 5 Jahrg.,
Mai, 1882, p. 201; also, I. Althaus, "Treatment of Obstinate
Constipation by Faradization of the Bowel," _Lancet_, London, 1867, ii.
606.]
In the relaxed condition of the abdomen in women who have borne {654}
children or in old persons the wearing of an abdominal support
sometimes gives help and comfort.
The best diet for cases of atony of the colon and rectum is one which
is easily digested and has a moderate amount of waste, as a full colon
will stimulate muscular action. Various articles are suggested with a
view to excite peristalsis by irritation of the mucous surface, but as
such substances are in themselves insoluble and innutritious, it is
unwise to resort to them. The following list includes the foods
suitable to such cases: Fresh vegetables, as spinach, raw or stewed
tomatoes, lettuce, kale, salsify, peas, asparagus, kohlrabi, and other
summer vegetables; in winter canned vegetables, if well prepared, take
their place. Among fruits, fresh fruit in general, especially grapes,
peaches, and oranges; dried fruit, as figs, raisins in small quantity,
stewed prunes, and baked or stewed apples, can be tried.
Too much vegetable matter is harmful, as the bowel is filled with an
excess of waste, much of which is undigested food; the quantity must be
regulated by the appearance of the stools and by the success of the
regimen. If the blockade continues obstinately, the vegetable diet
should be reduced. The microscope in many cases can alone decide the
amount of undigested vegetable matter. Meats are all advisable in
moderation. The least digestible, as ham and veal, are to be avoided.
Graham-flour bread, brown bread, or bran bread are better than bread
made of the best bolted flour. The first is more digestible, and bran
bread[46] is thought to increase peristalsis, but this is a doubtful
effect. Oatmeal well boiled, fine hominy, corn meal, or cracked wheat
with milk are pleasant and digestible. A cup of café au lait at
breakfast or before breakfast is the best morning drink;[47] it has a
laxative influence. Tea is thought to have the opposite effect. Milk at
breakfast answers well for those who take it with relish. An orange on
rising in the morning is a pleasant remedy.
[Footnote 46: "The Efficacy of Bran Bread in relieving Despondency ...
dependent on an Irregular and Constipated State of the Bowels," _Journ.
Ment. Sci._, London, 1858-59, v. 408-411.]
[Footnote 47: "Treatment by Café au Lait," _Gaz. des Médecins prat._,
1840, No. 4, p. 13.]
Certain drugs are called for to aid these measures in giving tone
directly or indirectly to the weakened bowel muscles. Strychnia stands
first, but it woefully disappoints one who trusts much in the
theoretical arguments for its use. In fact, it may be said of all drugs
given for constipation that they stand in a very subordinate rank to
the measures already discussed. They should be thought of last, not
first, and but little confidence should be put in the vaunted value of
new drugs. Strychnia can be combined in anæmia and debility with the
dried sulphate or carbonate of iron, and with quinia or arsenic,[48] or
in feeble digestion with dilute hydrochloric acid and pepsin.
Belladonna was advised by Trousseau as a stimulant to unstriped
muscular fibre, and it can well be given with strychnia; ipecacuanha
and atropia are approved of in conjunction.[49] A pill of ergot,
belladonna, and strychnia would answer the indication of a feeble
peristalsis. DaCosta has suggested giving one drop {655} of the fluid
extract of belladonna with compound tincture of gentian or cinchona
three times daily after meals. The sulphate or valerianate of zinc,
oxide of zinc, extract of valerian or gentian, capsicum, or black
pepper can be tried in pill form with belladonna and strychnia.
[Footnote 48: Bartholow thinks arsenic overcomes constipation when due
to deficient secretion and dryness of the feces (_Mat. Med._, New York,
1879, p. 129).]
[Footnote 49: Legros and Onimus, _Journal de l'Anat. et de la Phys._,
t. vi. pp. 37 et 163. Ringer says one grain of ipecacuanha taken while
fasting each morning will relieve constipation from torpor
(_Therapeutics_, New York, 1882, p. 438).]
These remedies are slow-acting, and in the mean while the bowels must
be moved artificially, methodically, and taught to act at stated hours.
For this purpose a small enema of cool or cold water at the same hour
every day after breakfast does well. It is irrational to distend the
bowel, already weakened by distension, with large enemata of warm
water. Recourse should not be had to this until all hopes of effecting
a cure are gone, or only as an occasional remedy in impacted
accumulations where the mass must be softened before it can be removed.
If the enema does not in time empty the colon sufficiently, laxatives
will have to be taken with some regularity until the habit is created.
A tumblerful of water with or without a teaspoonful of salt, or a
tumblerful of any alkaline water charged with carbonic acid, taken on
rising in the morning, may prove effective. A tablespoonful of sweet
oil at night acts well as a lubricator and softens the feces. If these
more simple means fail, it becomes unfortunately necessary to give a
purgative drug: any one of this class can be combined with strychnia,
belladonna, vegetable tonics, and iron. Those to be preferred are
aloes, colocynth,[50] and podophyllin. The compound podophyllin pill or
a pill of one-sixth of a grain of belladonna and podophyllin at night
or three times daily, the pill of aloes and myrrh, or the Lady Webster
pill, are well-approved forms of administration. A compound rhubarb
pill acts well if taken after dinner.
[Footnote 50: A few drops of the Prussian tincture of colocynth several
times daily is advised by Ringer (_Therapeutics_, New York, 1882, p.
642).]
If one desires to select a purgative which will probably increase the
outflow of bile, selection can be made from the following drugs:
podophyllin, aloes, rhubarb, colchicum, euonymin, colocynth, calomel,
jalap, sodium sulphate, potassium sulphate, cream of tartar; and among
the rarer alkaloids iridin, sanguinarin, physostigma, and juglandin.
These, according to Rutherford, Vignal, and Dodds, increase the
secretion of bile in fasting animals. Ox-gall and pig-gall are
laxatives only; they have no effect on the liver, but can be added to
other purgatives in pill forms.
Salines largely diluted may be given to strong adults: Epsom or
Rochelle salts quite early in the morning, a solution of sulphate of
magnesia with dilute sulphuric acid, to which dried sulphate of iron
may be added, are quite popular; and of the bitter waters, Hunyadi
Jânos, Friedrichshall, or Pullna water serves the purpose. One grain of
sulphate of quinia added to a saline will increase its effect. The
milder laxative waters are to be preferred to the bitter waters. The
Saratoga waters, Congress, Geyser, Hathorn, answer the purpose taken
early in the morning, or among the European springs those of Kissengen,
Plombières, Marienbad, Homburg, Seltzer, or Leamington in England, are
not too active in their effects. In atonic constipation, the form now
under consideration, the laxative chalybeate waters are indicated where
there is anæmia or debility. These are represented by the Columbian,
Pavilion, Eureka, and Excelsior Rock among the Saratoga waters, and by
the Bedford Springs water.
{656} It is well to administer a number of drugs in rotation in
habitual constipation, as the susceptibility to a particular drug is
lost after continued use. Increase of the dose is the usual method to
offset this result, but it is irrational to meet exhaustion by
over-stimulation. Rest of the part stimulated by using a remedy which
brings about the result in a different way is the wiser course. The
dose should be gradually reduced, tempting the bowel to act more and
more without aid. Among the laxatives which can be borne in mind in
alternating treatment the following list includes some which can be
used with advantage: the fluid extracts of rhamnus (buckthorn) and
cascara sagrada; alum, which is called for in certain forms of atony;
sulphur in the form of confection or sulphur with guaiacum[51] (half a
drachm of each in powder at night); the wine of colchicum (five drops
or more three times daily), advantageously used in gouty or rheumatic
persons; the infusion or tincture of euonymus; the tincture of benzoin;
senna in fluid extract and in the compound powder of liquorice.
[Footnote 51: Fuller, _Lancet_, London, April 23, 1864, p. 459.]
Infants and children should be cured of constipation without purgatives
if possible. Attention to the diet of the infant, and close inspection
of the stools to see the effect of the food given, will guide to a
proper system of feeding. Breast-milk is the best remedy; next, a food
which most nearly resembles mother's milk--cow's milk properly diluted
with barley-water, oatmeal-water, or rice-water--stands first.
Condensed milk, given in barley- or oatmeal-water, is a second and
excellent substitute in cities. Antacids prevent a too rapid
coagulation of the casein and the formation of curdy lumps. Lime-water
with milk or bicarbonate of potassium or of sodium may be administered
with the food or before it. The quantity of food must be lessened until
the child can digest all it takes.