4 CONSTIPATION IN ADULTS AND CHILDREN (From Luschka, " Die Lafie tier Uaiichorgane," etc.) Frontispiece, 19, Right lobe of the livei"; 20, Quadrate lobe; 21, Left lobe of the liver; 22, The suspensory (broad) ligament of the liver, cut off; 22*, Fundus of the gall-bladder; 23, Oesophageal (upper) oriflce of the stomach ; 2i, Cul-de-sac of the stomach, partly overlaid by the left lung; 25, Pyloric end of the stomach; 26, Section of the stomach which lies in the epigastrium, and is partly covered by the liver ; 26 *, Arteria gastro- epiploica dextra, corresponding to the course of the greater curvature of the stomach ; 27, Csecum ; 28, Appendix Vermiforrais ; 29, Ascending colon ; 30, Right colic flexure ; 31, Transverse colon ; 32, Left colic flexure ; 33, Descending colon ; 34, Dotted lines, showing position of sigmoid flexure underneath the small intestines ; 35, Small intes- tines in the arrangement most commonly found ; 36, Obliquely ascending end of small intestines ; 37, Summit (apex) of bladder covered by peritoneum ; 38, Anterior and lower portion of bladder (in a state of moderate distention and reaching beyond upper border of pelvis) free from peritoneum. CONSTIPATION ^ m ADULTS AND CHILDREN WITH SPECIAL REFERENCE TO HABITUAL CONSTIPATION AND ITS MOST SUCCESSFUL TREATMENT BY THE MECHANICAL METHODS BY H. ILLOWAY, M.D. FORMERLY PROFESSOR OF THE DISEASES OF CHILDREN, CINCINNATI COLLEGE OF MEDICINE AND SURGERY ; FORMERLY VISITING PHYSICIAN TO THE JEWISH HOSPITAL, CINCINNATI; ETC., ETC. MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK OF THE NEW YORK COUNTY MEDICAL ASSOCIATION, ETC. THE MACMILLAN COMPANY LONDON: MACMILLAN & CO., Ltd. 1897 AH riffhin reserved Copyright, 1897, By the MACMILLAN COMPANY. NortooaH JPtcBS J. S. Cashing & Co. - Berwick Si Smith Norwood Mass. U.S.A. TABLE OF CONTENTS Part I SECTION I CHAPTER I TO Anatomy of the Intestines. (With reference mainly to the large bowel; its position in the abdominal cavity; the internal arrange- ment of its mucous membrane.) The vessels. The nerves — show- ing the relation of the bowels to the cerebral and the spinal centres CHAPTER n Platus CHAPTER ni Intestinal Peristalsis. Defecation CHAPTER IV I'^ces (appearance thereof under the microscope) - . ' . CHAPTER V Definition; Etiology; Classification CHAPTER VI Acute Constipation ; Etiology. {En parmthese, an account of for- eign bodies that may cause such, with histories of cases to illustrate the mode of treatment when sharp bodies, as knives, etc., have been introduced) .......... CHAPTER VII "Chronic Constipation ; Etiology. The various maladies that may give rise thereto — Foreign bodies (with histories of cases) — Mal- formations of the intestines — Dislocation of the intestine — Essen- tial primary atrophy of the intestine vii Vlll TABLE OF CONTENTS CHAPTER Vm Spastic Constipation. Enterospasin — Enterospasra and atony — Spasmodic stricture of the rectum — Spasmodic contraction of the sphincter of the anus without fissure — Irritable sphincter . . 94 CHAPTER IX Atony OF THE Intestine. Causes — Mode of action . . .105 CHAPTER X Symptomatology. General and local symptoms .... 112 CHAPTER XI Diagnosis. Methods of examination ; percussion, palpation, inflation — Faeces, microscopic examination of. Prognosis 132 CHAPTER XII The Consequences of Constipation. Haemorrhoids — Anal Fis- sure — Typhlitis — Appendicitis — Enteritis membranacea — Proc- titis— Fsecrfl tumors — Dislocation of the bowel — Ulceration of the bowel — Ulceration with hypertrophy — Diverticula . . 166 CHAPTER XIII The Consequences of Constipation, Cont. Diarrhoea with consti- pation — Ileus — Jaundice — Torpid liver — Atony of the stomach — Auto-intoxication 176 CHAPTER XIV The Consequences of Constipation, Coni. Disturbances of the nervous system — Pyschoses — * * * — Chlorosis . . ■ 185 SECTION 11— TREATMENT CHAPTER XV Treatment of Constipation due to Atony of the Intestine. Hygienic rules — Dietary regulations ; diet list — Exercise ; rules for same CHAPTER XVI Treatment of Constipation due to Atony, Cont. Massage ; gen- eral technic of — Special manipulations — Schedules of manipu- lations— Duration of treatment — Instrumental massage . • 243 203 TABLE OF CONTENTS ix CHAPTER XVII TO PAGE Treatment of Constipation due to Atony, Cont. Swedish move- ments — Machine gymnastics — Centra-indication to massage . 264 CHAPTER XVni Hydrotherapy. Special procedures — Schedule of temperatures for water 283 CHAPTER XIX Electricity. Modes of application 299 CHAPTER XX Medicines. Nux vomica (Strychnia) — Calabar bean (Physostigma) — Ergot — Zinc — Ammonii chloridum 305 CHAPTER XXI Effects of Treatment; Complication 308 CHAPTER XXII Treatment of Conditions related to Atony. Ileus — Paraly- sis of the intestine — Atony of the rectum ..... 317 CHAPTER XXIII Treatment of Atony of the Intestine dependent upon Morbid Processes. I. Constipation dependent upon intestinal catarrh — II. Atony from morbid processes elsewhere: 1. Xeurasthenia ; 2. Debility after protracted maladies ; 3. Disease of the heart . 324 CHAPTER XXIV Treatment of Spastic Constipation 333 CHAPTER XXV Treatment of Constipation due to Irritable Rectum . . 340 CHAPTER XXVI Treatment of Constipation dependent upon Genito-urinary Troubles 343 CHAPTER XXVII Fissure of the Anus 345 TABLE OF CONTENTS CHAPTER XXVIII -surgi- H^MORRHOiDs. Relief of the constipation due to them — Non-i cal treatment of ggg CHAPTER XXIX Oil Injections. Technic of 359 CHAPTER XXX Other Methods of Treating Constipation (recommended by various writers). 1. Stretching of the sphincter aui; 2. Applica- tion of boracic acid to the anus; 3. Treatment by river-gravel (Flusskiesel) ; 4. By suggestion 365 CHAPTER XXXI Treatment of Constipation in Old People 369 CHAPTER XXXII Formulary 383 Part II CONSTIPATION IN INFANTS AND CHILDREN CHAPTER I Introduction ; Classification. Congenital Constipation. Malformation of the rectum and anus — Of the colon — Of the small intestines — Malplacement . . 412 CHAPTER n Acquired Constipation. Acute Constipation, Etiology 418 CHAPTER III Chronic Constipaton, Etiology 422 CHAPTER IV Habitual Constipation, Etiology . . . o c . • 428 TABLE OF CONTENTS XI CHAPTER V TO PAGE Habitual Constipation due to Atony, Cont. .... 434 CHAPTER VI Habitual Constipation due to Atony, Cont. Habitual constipa- tion in older children 437 CHAPTER Vn Symptoms and Diagnosis 440 CHAPTER Vni Treatment of Constipation due to Atony of the Intestine (Infants). General measures — Special measures (remedies, injec- tions) — Massage — Secondary measures 455 CHAPTER IX Treatment of Constipation due to Atony of the Intestine, Cont. Older children 458 CHAPTER X Some Anatomical Considerations ....... 464 CHAPTER XI Massage. Preliminary considerations 469 CHAPTER XII Massage. Technic of manipulations for infants and young children 480 CHAPTER XIII Spastic Constipation. Fissure of the Anus 484 Formulary CHAPTER XIV 488 LIST OF ILLUSTRATIONS Part I PAGE Frontispiece, showing the abdominal organs in position. The duodenum and surrounding structures 4 The c£ecum, showing funnel-shaped terminal extremity of the ileum, and the appendix vermiformis 7 The large bowel in position 8 The caecum laid open, showing orifice of appendix vermiformis . . 10 The sigmoid flexure . . 12 The sigmoid flexure 13 The external sphincter of the anus, perineal muscles in man ... 15 Sacculi Horueri 18 Diagram of the nerves of the intestinal tract .21 The plexus of Auerbach 23 The plexus of Meissner 24 The male perineum, showing distribution of nerves .... 25 Normal fa3ces 41 Human colon, congenital giant growth . 67 Diverticulum, congenital, of the sigmoid flexure 77 Illustration of enteroptosis . 80 Upward dislocation of transverse colon 81 Dislocation of the sigmoid flexure to the riglit 85 Abdomen, where to examine 110 Arrangement of apparatus for inflating the bowel with gas . . . 122 Arrangement of apparatus for inflating the bowel with air . . .123 Crystals of haematoidin 127 Teichmann's haemin crystals 127 Colored Plate, showing microscopic appearance of some constipated faeces, between pages 128 and 129 Demi-schematic view of the external surface of the ampulla of tlic rectum xiii xiv LIST OF ILLUSTRATIONS Demi-schematic view of the internal surface of the ampulla of rectum False diverticula, of the large bowel Distention diverticula, of the small intestine Diverticulum of the ileum Bandages for the abdomen Abdominal bandage .... Effleurage with the tips of tlie Augers Frictions with the thumb . Petrissage with the thumb . Petrissage with the tliumb and finger Diagrammatic illustration of position of patient for massage Division of the belly with one hand , Division of the belly with two hands Eolling of the belly with one hand Rolling of the belly with two hands . Petrissage of the abdominal walls TheKammgriflr . Kneading of the belly . Punctation .... Circular effleurage Position of hands for operator To brealv up indurated faeces in caecum and ascending colon To breali up indurated fasces in transverse colon Manipulation for ascending colon, liver, and gall bladder Transfer movement, for caecum and ascending colon Transfer movement, for transverse colon .... Transfer movement, for descending colon and sigmoid flexur Position of hands for petrissage, of sections of colon Position of hands for petrissage, of sections of colon . Kneading and raising of sigmoid flexure Vibration of solar plexus . Hacliing of the belly . Clapping of the belly . Tapotement i\ I'air comprini6 Beating of the sacrum Kahn's roller Figs. 1-10, Active movements the LIST OF ILLUSTRATIONS XV PAGE Figs. 1 1-18, Movements against resistance 250-2o5 Figs. 19-23, Passive movements 2o7-258 Fig. 24, Row boat of Sachs 2C1 Fig. 25, Row boat of Ewer Fig. 26 a, Movements witli Saclis restaurateur 261 Fig. 26 b, Goodyear's pocket gymnasium 261 Outline of enlarged spleen 262 Self-acting clysopump 265 Force pump Application of the wet sheet 274 Sprinklers • ^''^ Rectal electrodes Bipolar rectal electrodes 289 Atzperger apparatus ^37 Winternitz's device 338 Bottle for generating carbonic acid 339 Psychrophor 341 Hajmorrhoidal bandage 349 Tip for syringe (for oil injection) 355 Rectal bougies • 361 Whitehead's instrument 361 Part II Frontispiece I. Abdomen of infant twelve days old laid open, small intestines in situ. Frontispiece II. Same, showing large bowel, liver, and stomach. Congenital contraction of the ascending and transverse colon, etc. . 395 Congenital obliteration of the small intestines ...... 401 Ileum with diaphragms 407 The abdominal viscera of a new-born infant held in position . . 462 Diagram of the above 4G3 Diagram showing direction of manipulation 471 Manipulation II. for infants 471 Diagram showing direction of manipulation 472 Manipulation III. for infants 473 Manipulation IX., thumb movement 476 PART I CONSTIPATION IN ADULTS COIfSTIPATION m ADULTS SECTION I CHAPTER I ANATOMY OF THE INTESTINES The part of the human body that principally concerns us here is the intestinal canal, consisting of two distinct and characteristic parts, — the small intestines and the large bowel. The small intestines constitute by far the major part of the intestinal tract. The average length in the adult male (between the ages of twenty and fifty) is twenty-two feet, six inches ; in the female it is twenty-two feet, four inches. Exceptionally it is found, both in the male and female, longer or shorter by some feet. The intestinal tract proper begins at the stomach, from which it is separated by the sulcus pyloricus, with that portion known as the duodenum. Ever since the days of Herophilus the small intestines have been divided into three parts, — the duodenum (twelve fingers, eight to ten inches), the jejunum, and the ileum. There is, how- ever, no line of demarcation that separates the duodenum from the jejunum, or any distinctive feature by which to 3 4 CONSTIPATION IN ADULTS recognize the one from the other. Luschka has therefore proposed that the duodenum and jejunum be grouped together as one part and be called the pancreatico-bilious intestine (intestinum pancreatico-biliosum). The duodenum takes its origin at the pyloric extremity of the stomach, on the right side of the epigastrium, about the level of the last dorsal vertebra, and ends on ■2 3 The Duodenum and surrounding Structures. {Sappey.) 1 Para horizontalis superior, thrown back to the right; 2, Pars desce7ier se, constipation; but combined with some of the other etiological influences named, it is certainly most potent in developing a coprostasis, and m 1 See the chapter on the "Physiology of Intestinal Movement." 2 See also Birch, Constipated Bowels, 1868. PERFORMANCE OF PHYSIOLOGICAL FUNCTION 101 maintaining it. In its severest form, the pendulous belly, it is not only the sole cause of the constipation, but it is the most difficult, and not infrequently the insuperable, obstacle to the recovery of the patient. 7. Obesity. — Large deposits of fat about the abdomi- nal parietes and the intestines tend to impairment of normal muscular vigor, to atony, to constipation. 8. Prolonged Mental Work; Prolonged Mental Worry; General Depressing Influences, lower the irritability of the nervous system, and, in consequence, all the physiological functions are very markedly slowed. 9. Bad Teeth, or Want of Teeth, prevent perfect masti- cation, and compel either the deglutition of badly masti- cated food, which will subsequently develop a dyspepsia, or a resort to a pap and slop diet. 10. Old Age. — Besides the feebleness of muscle, the torpidity of the secreting organs incident to this epoch of life, the lack, in many cases, of good masticating organs, the bland character of the food, the want of necessary exercise, are important factors in perpetuating a condition of constipation. I have not counted among the etiological factors the habit of pill-taking, which many authors hold as the chief cause of the evil, for the reason that I do not believe that it is so. My experience, both in hospital and private practice, has demonstrated to me that "purgative-taking" is not the fons et origo of constipation ; rather the reverse, pur- gative-taking is the residt of constipation. That it finally aggravates the derangement, — of this there can be no doubt ; the excessive irritation of the purgative exhausts 102 CONSTIPATION IN ADULTS the normal irritability of the intestinal tract, especially when the drug is so frequently repeated and in ever- increasing doses ; a condition of over-fatigue, of exhaus- tion of the muscle, is established. An over-indulgence in very coarse vegetable foods may produce the same result.' The great abundance of coarse residual matter causes an excessive irritation of the bowel just as do purgatives, and constipation, as a result of the exhaustion of the normal irritability, follows. TTie prolonged use of warm or lukeivarm or emollient injections is likewise injurious.^ Their mode of action is readily understood. They cause turgescence of the parts, they enervate the muscle, they dull the normal irritability of nerve and muscle. Among the incidental causes of constipation, and to whicli Birch 3 has already called attention, is the inadvertent con- sumption of certain derivatives of the mineral kingdom, whicli tend to dry up the secretions of the bowels, and to lump and harden the faeces. These are alum, the salts of lime, the salts of lead, iron, and copper. Alum is found in adulterated flour. It is said to be fre- quently used by millers to give their flour a lustrous white- ness. It is a constituent of many baking powders, and thus gets into the bread and other dietary preparations that we con- sume. Lime salts: The sulphate of lime is said to be used extensively in the preparation of various confections. The drinking water may be highly impregnated with the salts of lime, as we find in the well water of many country districts. Birch states that he has seen a number of cases of constipation so produced. In young infants it may be the lime-water added 1 Rosenheim, loc. cit. Boas, Diiit u. Wegweiser f. Darinleidende. 2 See Nouveau Dictiounaire de Med. et de Chirurg. Pratique. Article "Constipation." 8 Birch, Constipated Bowels, 1868. PERFORMANCE OF PHYSIOLOGICAL FUNCTION 103 to their milk. Salts of lead : Various cheap candies are colored with the red oxide or yellow chromate of lead. Numerous cases of constipation with colic, in children, from the consump- tion of such candies have been reported. Even graver con- sequences, intoxication and death, have resulted therefrom. This offence against public health merits the earnest attention of the authorities. The drinking water may be impregnated with lead from the pipes through which it is conducted. Copper we get with our pickles and various other like condi- ments. Iron : The prolonged use of preparations of iron may lead to constipation. Drinking water rich in iron, as the waters of St. Louis, Michigan, may have the same effect. Mode of Action : Though some of the etiological factors just named act chiefly upon the mucous membrane, obtunding its sensi- bility and the sensibility of its nerve filaments (as the neglect of the calls of nature, habitual use of food con- taining but little residual matter, adulterated food as just referred to), whilst others act primarily upon the muscular structures (as indolent habits, want of sufficient exercise, insufficient oxygenation), and others again upon the nerves governing the process of evacuation (as read- ing at stool, prolonged mental worry or occupation), nev- ertheless, the effect of all these factors is, in reality, one and the same, to wit, a loss of normal tone, of normal vigor, in the muscular coats of the intestinal tract, — an atony of the bowel. It can be readily understood that an atony could not occur, that the muscles could not fall into this lethargic state, if the mucous membrane, if the ulti- mate nerve filaments, retained their normal sensitiveness. It is generally admitted that, as has been indicated at the outset of this chapter, the abnormal — it cannot be 104 CONSTIPATION IN ADULTS called pathological — condition present in the great ma- jority of cases of habitual constipation is an atony of the intestine} An atonic condition of the intestine is not infrequently one of the sequelae of the infectious diseases that are attended with abundant discharges from the bowels, as typhoid fever, dysen- tery, cholera. Here also the atony is, in greater part, a conse- quence of the preceding hyper-irritation. Atony of the intestine is one of the prominent features of chlorosis ; so prominent, indeed, that Sir Andrew Clark was disposed to look upon the disease as a copraemia. However this may be, this much can be said, that, the disease once devel- oped, all the conditions thereof tend to make the coprostasis more obstinate. It is a generally admitted fact (and one that I hold as of the greatest importance) that there is insufficient oxygenation. 2 The stomach is very much disturbed ; the appe- tite is poor and perverted ; there is a distaste for the grosser kinds of foods, and what nutriment is taken is in concentrated form, and even of this but little is consumed. There is a feel- ing of languor, of fatigue, which opposes all exercise and active exertion ; a loss of tone in muscle, shared by both stomach and bowels.^ 1 Fleiner, loc. cit. Rosenheim, loc. cit. 2 Osier, Principles and Practice of Medicine. Rosenbach, O., Enstehung u. Hygienische Behandlung der Bleichsucht. 3 Rosenheim, loc. cit. CHAPTER X SYMPTOMATOLOGY Constipation has but few characteristic symptoms ; when it has been said that the faecal evacuations are retarded beyond the normal period, that the stool is hard and dry, and that the person is unable to have a full and free discharge without having recourse to a purgative, its special features have been described. It is true, as has been pointed out,^ that nature will, after a longer or shorter period of time, — from four days to three weeks, — make an effort to dislodge the accumulated material. It is, however, generally unsuc- cessful, always so when the constipation is due to atony, in that only a very few hard scibala, which had been pushed far down into the rectum by the vis a tergo and had set up an unusual irritation about the sphincter, are discharged, whilst the bowel above still remains loaded ; and even this does not occur frequently, once the constipation has become a habit. It is correct, therefore, to count among the characteristic features of this derangement the neces- sity of a purgative for the production of a full and free evacuation. In addition to these special features, we have certain other phenomena, some of a local, some of a more general character, that present themselves to us in constipation. 1 Kaczorowski, Deutsche mediz. Wochenschrifl, 1882. 105 106 CONSTIPATION IN ADULTS General Symptoms. — The tongue is coated ; usually it is a thick, white fur ; not infrequently, a yellowish one. The breath is offensive. The appetite is poor, maybe 7iil; sometimes dyspeptic phenomena, as eructations, heavi- ness after eating, — even after small meals, — nausea, are noted. Occasionally there is a disgust for food ; the per- son cannot look at it. A bad taste in the mouth. Headache is of frequent occurrence. It is really rather a feeling of fulness, of heaviness, of the whole head, or more particularly of the frontal portion, than a pain. Vertigo, rushes of blood to the head, are complained of. In one case of prolonged constipation, due to anal fissure (which is reported more in detail further on), I saw 2^Tofound stiqoor, so profound indeed that it was only with great difficulty that the patient could be aroused, and then he would murmur only a few unintelligible words, and relapse into his former state. This stupor had lasted, at the time I saw him, for over three weeks. The perturbation may be more general. It may be a feeling of malaise, of hebetude, that renders the person incapable of doing any work. It may be a hypochondri- acal condition that has supervened ; the person is morose, moody, and preoccupied with himself. Again, it may manifest itself in a marked irritability; he (or she) is quarrelsome ; nothing is right, nothing is proper, and he (or she) has a grievance against the whole of creation. I once knew a very eloquent professor who suffered from chronic constipation in whom this feature stood out so prominently as to become quickly known to the students, and they could tell at once, when he appeared on the rostrum for his lecture, by his manner and look, whether SYMPTOMATOLOGY 107 he had had his clyster and an ample evacuation that morning, or whether his duties had kept him therefrom. Rosenheim' mentions alternate sensations of heat and cold. I have not observed this except in neurasthenics, and have ascribed it rather to an aggravation of the neurasthenia caused by constipation, than to the constipation itself. Senator ^ holds that the phenomena are due to intoxication by sulphuretted hydrogen gas (SHg), and bases his belief upon a case that came under his observation. At a later period, in a discussion of dyscrasias, he reaffirmed this view.^ To this it may be opposed that the case upon which this view is mainly based could very possibly have been, and the whole history points very much that way, one of ilio-csecal intussusception. Such a state is, of course, altogether different in its effects upon the intestinal processes, and no conclusion could be drawn therefrom that would be valid for other conditions. Moreover, there is a possibility, even a probability, that in the case re- ferred to a considerable quantity of sulphuretted matter was introduced from without. Besides all this, the investigations of Ruge,^ of Novack and Brautigam,^ as already mentioned by Rosenheim, very clearly controvert such an opinion. These investigators have found that ordinarily the quantity of SH^ in the admixture of intestinal gases is less than 0.1 per cent, rarely more, even when the f seces are long retained, and such a quantity is much too small to cause phenomena of intoxication." ^ Loc. cit. 2 Senator, " Ueber einen Fall von Hydrothionamie," etc., Berlin, klinische Wochenschrift, 1868, p. 254. 3 Zeitschrifl f. klinische Mediz., Bd. VII. * Ruge, Wien. Silzumjsherichte d. Akad. der Wissenschaften, 1862, p. 729. Foster, Human Physiology. ^ Nowack u. Briiutigain, Muenchener mediz. Wochenschrift, 1890. * The experiments of Bergeon (Nouveau Traitement cies Affections des Voies Respiratoires, etc., par les Injections Rectales Gazeuses, V. Morel, Paris, 1886) and others {Medical News, Phila., 1887), in the treatment of tuberculosis, demonstrate that large quantities of SH,, can be introduced into the intestinal tract without causing the least systemic disturbance. 108 CONSTIPATION IN ADULTS The explanation of Rosenheim ^ that they are caused by auj?- meiited putrefaction in the albuminoids, presents as many difficulties. 2 My own opinion is that they are based upon disturbances of the nervous, circulatory, and glandular systems of the intestinal tract. All of these must suffer, more or less, in constipation, from the filling up of the bowel and the pressure necessarily exerted by the hardened masses. It may also be possible that the diffusion of CO2 into the intestinal canal 3 is interfered with and its consequent accumulation in the blood may con- tribute to the production of the perturbations described.* We see similar phenomena in persons who are very much confined to their room, in whom there is an insufficient oxygenation, and consequently an increase of COg (beyond the normal limit) in the system. As to the loss of appetite alone, there is but little diffi- culty in its explanation. The atony of the intestinal mus- cles soon involves those of the stomach. The movements of this latter organ are very much slowed, and conse- quently the chymus is retained therein for a much longer time. The chemismus itself does not seem to be impaired. 1 Log. cit., p. 502. 2 The investigations of Von Pfungen (Zeitschrift f. klinische Mediz., Bd. XXI.) and others have all been made on persons in whom grave or- ganic disease, as peritonitis, myelitis, existed, and in whom, therefore, all the bio-chemical processes must have been seriously affected. It may be justly questioned whether what holds good under those conditions will apply to constipation without the co-existence of organic disease; with an otherwise normal condition of the digestive tract, stomach included. Von Pfungen himself there says that where the secretion of HCl in the gastric juice is not diminished, the putrefactive processes occurring in the albuminoid mat- ters in the large bowel are at about the normal. See "Auto-intoxication," in following chapter. * Normally a certain amount of C0„ is diffused from the blood into the intestinal tract. See chapter " Flatus." * See Senator, Berlin, klinische Wochenschrift, loc. cit. Hoppe-Seyler, Physiol. Chemie. SYMPTOMATOLOGY 109 In the intestinal canal the digestive process is not interfered with ; it is possible that there may be a greater splitting lip of the albuminoids in the large bowel.^ How the bad breath is produced, it is difficult to say. Whether it be that some of the inhaled air that is carried into the stomach passes thence into the intestinal canal, and becoming charged there with the odors from the fjBces, or with volatile gases, is carried into the circula- tion and excreted through the lungs, or that these odors or gases pass upwards and through the stomach, and mingle with the expired air, is something yet to be determined. Local Symptoms. — Flatulence : ^ a sense of distention ; a feeling of fulness, of heaviness in the belly. The abdo- men may be distended symmetrically, or only in part thereof. Rolling and purring noises in the bowels. No tenderness of the abdomen. Colics not infrequent ; more rare in habitual constipation due to atony. Stitches in the side, under the liver or under the spleen ; in the back, in the lumbar region, sometimes as high up as the inferior angle of the scapula, which cause the persons considerable suffering and much uneasiness as to the state of their liver or of their kidneys. The pains are transitory ; there is an interval of rest of longer or shorter duration ; then the person feels something shooting up his bowels into the locality named, and the pains at once follow ; they are wandering, being now on one side, then on the other. They are more severe when the person sits or lies down, and are relieved by standing or walking. ^ Von Pfungen. 2 Accumulation of flatus. 110 CONSTIPATION IN ADULTS All these phenomena are provoked hy the distention of a loop or loops of intestine by accumulated flatus and the irregular peristalsis thus therein excited. A full discharge of wind per rectum will quickly effect their disappearance. Itching at the Anns. — I have known constipated persons in whom the call of nature was expressed in an itching about the anus, which grew more intense the longer the evacuation was delayed, and disappeared at once with the discharge. Some of my patients informed me that they would have no rest until they had taken an active purga- tive, and thoroughly cleansed their bowels. If the abdominal parietes be not too thick, the large bowel can be very readily palpated. If a condition of constipation exists, we will find more or less large faecal masses accumulated therein, which can be readily felt, and can be demonstrated to be faecal matter by the ease with which they are broken up with the fingers. They are most numerous and most readily felt in the descending colon and the sigmoid flexure ; in cases of long standing, they can be found almost always in the transverse, and even in the upper portion of the ascending colon. The faeces are harder and drier than normal ; frequently hard and dry, and are usually evacuated in the form of scibala, varying in size from a hickory-nut to a horse- chestnut ; two to three scibala may be agglutinated to- gether, and thus form larger masses. I have seen them in the form of cylinders, and so hard that it required an axe to break them. They vary in color from a very dark brown to a black. There is nothing remarkable about the odor. SYMPTOMATOLOGY 111 The special features of enterospasm have been already described. As in all other ailments, so also here the symptoms given may be all present or the greatest part may be wanting (and this is not infrequently the case once the person has become habituated to the constipation), and between these two extremes we have the various and numerous gradations. CHAPTER XI DIAGNOSIS; PROGNOSIS Diagnosis — Examination The diagnosis alone of constipation is not a difficult matter. The patient himself will tell us that he is con- stipated, and when he has described to us the period of time intervening between one evacuation and the other, and when he has informed us that his bowels do not move without a purgative, without an injection, we can have no further doubts. Some difficulty may be encountered when we are confronted with that somewhat paradoxical condi- tion where the patient complains of diarrhoea, whilst in fact he is constipated. However, even here we can readily acquire certainty. A careful examination of the abdo- men, a careful examination of the large bowel, of the rectum, will disclose to us, if constipation be present, large masses of hardened faeces. The principal point in diagnosis is to differentiate whether the constipation that we are called upon to treat is that form which can be called idiopathic — habitual con- stipation — or whether it is produced by one of the many pathological processes that may give rise thereto. This must be done by exclusion. For this purpose we must acquire a full history of the patient ; we must carefully inspect his appearance and that of his body; we must 112 DIAGNOSIS; PROGNOSIS 113 examine carefully his abdomen, his bowels, his rectum, and finally the feeces must be carefully studied, both macroscopically and microscopically. By the inquiry into his history, we acquire valuable data as to the mode of onset of the constipation, the age at which it first manifested itself, and its duration. We learn whether at any time previous there was pain with the stool, whether there is pain with the stool now, before or after (ulcer, spasmus, fissure) ; whether the stools were admixed with recognizable blood; whether they were black and tarry (hasmorrhage of the bowel, high up) ; whether they contained or still contain large or small quantities of mucus, on top or closely intermixed. We learn therefrom whether there is any reason to sus- pect tubercle. It is very important to know as to the probability of a tuberculous condition, for tuberculous stricture ^ is a possible factor that must not be overlooked in the process of exclusion. We may get data as to the family history that will indicate to us whether malignant disease should be suspected. We will learn whether the patient has ever had strangulated hernia ; whether he has ever had dysentery, and possibly a subsequent contraction of the lumen of a section of the tube ; ^ whether he has had any of the manifestations of syphilitic infection, — and syphilis may give rise to a stricture in the bowel. We will learn whether the patient has had sexual ail- ments, as gonorrhoea, gleet, spermatorrhoea ; whether he is addicted to evil practices, etc., all of which are frequent ^ Treves, Intestinal Obstruction, p. 259. Koenig, Deutsche Zeitsckr. f. Chirurcjie, 1892. ^ Treves, loc. cit., pp. 255-26.S. 114 CONSTIPATION IN ADULTS causes, direct or indirect, of obstipation.' We will gather indications as to whether the patient is a neurasthenic or an hysterical individual or not. Finally, we learn whether a foreign body should be suspected or not. General inspection of the patient, of his body, will give weight to what we learn from his history as to tubercle, as to cancer. It will inform us whether the liver, the kidneys, the heart, must be looked to. It will thus greatly facilitate our examination. Local inspection of the abdomen will inform us whether it is normal or not ; whether it is distended, and if so, whether it is symmetrically distended. It will furnish us valuable information as to the state of the portal circula- tion, and thus inform us as to the condition of the liver. By a careful examination of the abdomen, we will be able to decide the question of effusions, of gaseous dis- tention of the bowels, of tumors of the abdomen. We will discover the state of the bowels, of the peritoneum, whether they are normal or not. We will learn the con- dition of the abdominal walls, whether they have their natural firmness, or whether they are relaxed or flabby. An examination of the large gut will at once disclose whether it is full or empty ; whether it has its normal lo- cation. We will learn as to pathological processes within or around it ; as to growths or foreign bodies. A careful examination of the rectum will at once inform us as to the presence or absence of accumulations of faeces, of hsemorrhoids, of polypi, of ulcers, of fissures, of malig- 1 A. Peyer, Die Nervosen Affectionen des Darraes. Wiener Klinik, Jan- uary, 1893. Lowenfeld, Die Nervosen Stoerungen Sexuellen Ursprungs, 1891. f DIAGNOSIS; PROGNOSIS 115 nant disease, of tuberculous, syphilitic, or dysenteric strict- ure, of shelves of mucous membrane, of foreign bodies ; will at once inform us as to the condition of the mucous membrane and parts below, whether they are normal or not. Of the greatest importance are the macroscopic and mi- croscopic examinations of the fseces. By the macroscopic examination we note the general appearance of the stool, whether it is scibalous or of cylindrical form ; its consist- ency, whether very hard, very dry, or only moderately so. We see the color thereof, whether brown, or black, or clay- colored. We note whether mucus is present in abnormal quantities or not. We discover the odor, and thus learn whether abnormal putrefactive processes are going on within the intestinal tract or not. We receive some indi- cations upon the questions of enterospasm. A microscopic examination will furnish useful infor- mation as to the food of the person ; whether it is too concentrated or not ; whether it contains too much indi- gestible matter; will inform us as to the presence therein of foreign matters, as blood, epithelium, mucus, and helminthes. The difficulty in diagnosis encountered is chiefly that connected with the question of stricture ; firstly, as to the presence or absence of a stricture higher up when the rectum is found free ; secondly, if a stricture is present, is it an organic or a spasmodic stricture ; thirdly, if organic, is it interstitial or extraneous (contraction of the inflam- matory products of the serous coat; shrinking of the mesentery).^ ^ Treves, Intestinal Obstruction. Il 116 CONSTIPATION IN ADULTS Strictures, interstitial, comparatively of not infrequent occur- rence, may result from any form of ulcerative disease, and may occur in any part of the intestinal tract. Those of the small intestines are generally located in the ileum, in the middle and lower portions thereof. They' are much rarer than those of the large bowel, as 1 : 5 or 1 : 6. Of the large bowel (in fact, of the whole intestinal tract), the rectum is the most frequent seat of stricture ; the sigmoid flexure is next after the rectum the most frequent site ; then come, in the order named, the colon ascendens, the left colic flexure {flexura coli sinistra}, the right colic flexure (flexura coli dextra). The caecum is rarely ever thus affected.^ When the abdominal walls are not too thick or too rigid, the large bowel can be readily palpated through them. Procedure. — The patient (if a child, the bladder must be previously emptied) is placed on a firm couch in the horizontal position, with the head slightly elevated (by a cushion or by the head-piece usually found on couches), with the lower ex- tremities extended. The examiner places himself to the right of the patient ; he can seat himself, which is more convenient, on the couch beside him. To facilitate reaching the bowel, the patient is told to keep his belly drawn in ; this will shorten the antero-posterior diameter of the abdominal cavity, bring the parts more closely together and thus more within our reach. To obviate the reaction, the muscular contraction and the consequent rigidity, which almost always follows when pres- sure is made upon the abdominal parietes, various expedients may be resorted to : (a) The patient is impressed with the necessity of keeping his belly loose, relaxed. (6) He is told to breathe deeply ; this has a very relaxing 1 Kelsey, loc. cit. Mathews, Diseases of the Rectum. Van Bureii, Lectures upon the Diseas. of the Rectum. DIAGNOSIS; PROGNOSIS 117 eifect upon the abdominal parietes. Furthermore, the deep inspirations, by causing deep descent of the diaphragm, will depress the bowel, especially the csecum, 2 to 4 cm., and thus enable us to locate the latter more readily. (c) The left hand is placed upon the abdomen, over the linea alba, with the larger part of the hand towards the left ; pressure is there made, and all the reaction concentrated under- neath it. The region to the right can now be palpated ; no reaction on this side now following as long as the pressure with the left is continued. Obrastzow uses the outer and thenar surfaces of the thumb of the left hand, and makes pressure as described. Or the left hand can be placed as described above, and firm pressure with a pushing away, to the left, motion made ; mus- cular contraction will be impossible. This is the expedient that I prefer. In cases of great rigidity of the abdominal walls, I have found it necessary to have the lower extremities flexed ; how- ever, only to a moderate extent, i.e. so that the knees were just somewhat elevated above the plane of the abdomen. This will usually effect a sufficient relaxation without being in any way a hindrance to the examination. Percussion. — I always make it a point to precede the palpa- tion with percussion. Beginning in the right inguinal region and running obliquely upward and outward, we have the caecum ; upwards to the under border of the liver, the ascend- ing colon, then to the right as far as the spleen, the transverse colon; here we must make our percussion more carefully, to differentiate the stomach from the colon. Then again down- ward to the crest of the ilium, the descending colon, and downward and inward in the left fossa iliaca to near the symphysis pubis, we have the sigmoid flexure. From percussion we will derive much valuable informa- tion as to the locality of certain special sections of the bowel, and also whether these sections are more or less distended or not. It will be a sort of outline for us on which to palpate. 118 CONSTIPATION IN ADULTS Palpation. — The CEecum and the sigmoid flexure may be palpated aftei- the fashion of the stomach ; the four fingers of the right hand, extended, are brought down perpendicularly on the part, with a light but firm pressure, raised and brouglit down again, until the whole section has been gone over. I prefer to palpate the csecum in the same way as I do other parts of the large bowel, to wit : the four fingers of the right hand are placed where the inner or upper border of the ctecum is supposed to lie, whilst the thumb is placed towards the lower or outer border ; gradually the fingers are pressed doAvn more deeply, moved about and approached slowly until the part desired is felt between them or in the hollow of the hand. For the ascending colon the fingers (of the left hand) are placed on the right flank. The four fingers, extended, are towards the back, whilst the thumb is forward and upward. The fingers are pressed in gradually deeper and deeper, other parts are pushed aside, and finally the ascending colon is grasped. The transverse colon is palpated in the same way, Avith this difference only, that both hands are used, one on either side of the umbilicus. The fingers are placed toward the upper, the thumb toward the lower border. The same movement already described is made ; the fingers are pressed in deeply, gradually, and slowly, the parts are rolled between the thumb and fingers until finally the bowel is grasped. Once seized, we can follow it for a certain distance, three to four fingers' breadth, to either side.i To palpate the sigmoid flexure, the examiner can remam m the position originally taken to the right of the patient ; then in palpating after the last method, he will place the fingers towards the outer or lower border, against the ilium, and the thumb along the upper border. I have often found it conven- ient to change the position, to place myself to the left of the patient, facing his feet. This gives me command of the right hand in the same position as for the ctecum. We can facilitate our examination by drawing on the abdo- men or by keeping in mind the following lines : 1 Obrastzow. See furtlier on. DIAGNOSIS; PROGNOSIS 119 1. From the umbilicus to the right anterior superior spine of the ilium. 2. From the umbilicus to the left anterior superior spine of the ilium. These are the Unece spino-umbilicalis. 3. From the right to the left anterior superior spine of the ilium. This is the linea inter spinalis. The exact point at which to palpate for the various sections of the large bowel are shown in the following figure. a, Left linea spino-umbilicalis; b, Right linea spino-umbilicalis; e, Linea inter- sptnalis; c, Csecum and ascending colon; d, Descending colon and sigmoid flexure. Caecum. — For the csecum we will begin on the right side, on the linea interspinalis upward along to the linea spino- umbilicalis ; here we will palpate from below upward, i.e. from the crest of the ilium toward the umbilicus. Ordinarily, ac- cording to Obrastzow, the csecum is found in the outer or in the middle third of the right linea spino-umbilicalis — removed about 5 cm. from the spine of the ilium, and not reaching the linea interspinalis. In cases of constipation the csecum may be filled to almost any extent with fsecal matter and gases, and is, therefore, more 120 CONSTIPATION IN ADULTS or less dilated. It may extend upward to the anterior third of the linea spino-umbilicalis and down to the linea interspinalis and beyond. In one case of enormous accumulation of faecal matter, grape-seeds, grape-skins, etc., the caicum extended from the anterior superior spine of the ilium, to the left, to within 2 cm. of the linea alba; downward it filled out the wliole inguinal region, reaching to the symphysis pubis. In another case, a patient aged seventy, suffering with chronic cystitis, greatly emaciated, and in whom the large bowel was very much distended with gas and stood out promi- nently upon the abdomen, the caecum looked like a large bologna sausage; it extended from below the linea interspinalis up and somewhat beyond the linea spino-umbilicalis, and from the anterior superior spine of the ilium, half-way into the middle third of the linea spino-umbilicalis. The transverse colon will be found between the umbilicus and a line drawn transversely across along the under border of the costal arches. In males it will usually be found from 1 to 3 cm. above the umbilicus ; in females it will be on a line running through the umbilicus, or 1 to 2 cm. beneath it. There are of course many incidents and accidents that may tend to change its position, either depressing or elevating it, as has already been described in the chapter on " Enteroptosis." All these things must be taken into account in the history of the patient, and borne in mind when the physical examination is made. The sigmoid flexure will be generally found at a distance of 3 to 5 cm. from the left anterior superior spine of the ilium toward the umbilicus on the left linea spino-umbilicalis, and crossing, also, downward, the linea interspinalis. In cases of constipation it may be distended to almost any extent. It may reach from the crest to the supra-pubic space and from the anterior superior spine to the umbilicus, depend- ing upon the length of time the constipation has lasted, and the extent of accumulation allowed. Sounds. — The cajcum may not give forth any particular sound on palpation ; usually, however, a rumbling or purring noise produced by the dislocation of flatus is heard. DIAGNOSIS; PROGNOSIS 121 In the transverse colon we may occasionally have a similar rumbling sound. In the flexura coli sinistra, where we may have marked tym- panitic resonance on percussion, we may get a rumbling sound, as loud, almost, as that of the csecum and from the same cause. In two cases I heard a splashing noise ; but I am not positive that it was produced in the bowel. In the one case the stomach gave a like splashing noise on palpation. No exact differential diagnosis could be made on this point, as the patients would not, under any circumstances, consent to the introduction of the stomach tube. However, from the location where the sound was obtained, far over toward the spleen, and judging from the point at which the gastric splashing sound was ob- tained in the other case, I believe that the splashing was really produced in the flexure, and was not merely a sound made in the stomach and conveyed from thence. Over the sigmoid flexure we may get the same rumbling, purring sounds or none.^ In all cases much depends upon the individual tendency to the production of flatus, which is more marked in older persons than in the young, and greater in those with depressed vitality than in persons in robust health. Having finished the palpation of the large bowel, we will palpate the rest of the abdomen, after the manner already described, causing the fingers to penetrate as deeply as pos- sible, but without causing the patient any pain. By palpation we will learn much as to the state of the bowel, whether it is empty or full; whether it contains much of hardened faeces or not. We will also learn whether there are any growths within the intes- tinal canal, or extraneous to it and pressing upon it. In females, we will also learn much as to the condition 1 Obrastzow, "Zur physikalischen Untersiichung d. Magens und Darius," DeutHch. Archivf. klin. Medicin, Bd. 43. " Ueber d. physikal. Untersuchung des Darms," Archivf. VerdauungskrankJieiten, Bd. 1. 122 CONSTIPATION IN ADULTS of the genital tract, whether the cause of the obstipation lies therein or not. Great assistance in examining the large bowel will be afforded us by inflation.' We can insufflate it with carbonic acid gas from an ordinary siphon of charged waters/ or we can inflate it with atmospheric air by means of a balloon. Arrangement of Apparatus for Inflation by Means of the Siphon (of Carbonated Water). The gas of one siphon of carbonated water (Seltzer, Vichy), amounting ordinarily to li to 2 litres, more than suffices to dis- tend the large bowel. 1 Senn, Experimental Surgery, 1889. Behrens, Ueber den Werth der kuenstl. Auftreibung d. Dickdarmes mit Gase u. Fluessigkeiten Goettingen, 1886. Danisch, Ueber d. Werth d. k. Auftreibung d. Darmes d. Gase, Ber- UnerMin.Wochenschrift,\Qm. Rosenheim, loc cit. «-Des 2 Schnetter, Deut^ches Archivf. kUnische Medicin, Bd. 34. Fougeray, Des Injections Rectale Gazeuses," Gazette des Hopitaux, 1886, p. 1116. DIAGNOSIS; PROGNOSIS 123 According to the more exact investigation of Damsch, one litre of air is all that is usually required. The bowel will be outlined to us very clearly upon the abdomen, and we will, moreover, have a good percussion surface. (By a careful percussion after inflation, we may be able to locate either a foreign body or a tumor or an induration that might not be otherwise perceptible.) By inflation we will very readily learn whether the gut occupies its normal location, or whether a dislocation of a section thereof has occurred. Arrangement of Apparatus fob Inflation by Means of the Double Balloon. We will learn the size of the large bowel, whether it is normal or not ; we will be able to see, to a consider- able extent, the configuration of the sigmoid flexure, and thus learn whether it is of normal or abnormal conforma- tion. By inflation we can distinguish whether certain abnor- mal growths that we may discover by abdominal palpation are of the intestines or not ; moreover, we will learn to what organ they do belong. By the distention of the bowels with gas the tumor is gradually pushed away, and it always retreats in the direction in which the organ of 124 CONSTIPATION IN ADULTS which it is a part is located. Tlius, tumors of the kidney will be pushed back, behind, and become imperceptible; of the liver, to the right, into the hepatic region ; of the spleen, to the left, into the left hypochondrium. Tumors of the stomach will be pushed upwards. By this method we may be able to discover a stricture that could not be found otherwise. The air will pene- trate the bowel up to the point of stricture, dilate it, and make its outlines distinct on the abdominal parietes ; whilst above the stricture, the part not dilating to that extent, its contour will not be so clearly outlined on the abdominal surface. Auscultation can be combined with the insufflation. The entrance of air into the free and dilating portion will be accompanied by a loud, hissing sound, which can be readily heard by the aid of the stethoscope ; whilst beyond the point of stricture the sound will be barely perceptible. Moreover, on percussion over the region of the large gut, as already described, we will find that the part this side of the stricture, freely insufflated, will give a marked tympanitic sound ; whilst above the seat of the stricture the sound will, in comparison, be flat. If we attempt to inflate the portion beyond the seat of stricture, we will find it attended with considerable difficulty ; it will require a much longer time, and then the distention will not be so marked as that of the portion below it.^ If it be a question of stricture, it is perhaps better to empty the bowel thoroughly, by means of a purge or large clyster, before inflating. 1 Rosenheim, loc. cit. DIAGNOSIS; PROGNOSIS 125 For the examiikation of the rectum, the patient should be placed in Sim's position, on the left side, with knees well drawn up. The buttocks being held well apart, the anus and exterior surroundings are carefully in- spected. With the well-oiled finger carefully introduced, the rectum can be explored through the whole of its lower four or five inches, and its condition learned (htemor- rhoids, contraction, etc.). Much may be learned, more- over, by this examination, as to the condition of the prostate, of the posterior urethra, of the ureters, of the ovaries, of the uterus, — all of which are at times impor- tant factors in the production of constipation. It may be necessary to supplement such an examination with an ocular inspection. This will be greatly favored by the use of a head-mirror, or of an electric forehead- lamp. As to the further details regarding the diagnostic points of stricture of the various portions of the intestinal tract and the various methods of examining the rectum, and the instruments employed therefor, the reader is referred to the works of Van Buren, Kelsey, Mathews, Cripps, and to the article -of Dr. H. A. Kelly,' in the Annals of Surgery, 1895. For special information with reference to the diagnosis of abdominal tumors, the works of the great gynecologists, the larger treatises upon sur- gery, and the lectures upon abdominal tumors lately delivered by Dr. William Osier in Johns Hopkins Hospital may be consulted. 1 " \ New Method of P]xainination and Treatment of the Diseases of the Rectum and Sigmoid Flexure," Annals of Sur (/en/, A-pril, 1895. 126 CONSTIPATION IN ADULTS Peristaltic movements may be visible sometimes upon the surface of the belly, when the abdominal walls are very thin and relaxed. Abnormally strong peristaltic movements so visible, is one of the features of all forms of stricture. They begin in the part above the point of contraction ; they may be either slow, vermicular, now gently rising, now disappearing, or they may manifest themselves as irregular, violent move- ments, attended with considerable suffering. The loop of intestine promenaded across the abdomen may be so much dilated that the small intestine may be mistaken for the large bowel, and the latter for the stomach. Rosenheim^ attaches much importance to this phenomenon and says : " In doubtful cases, visibility of the peristalsis will speak in favor of an already long-existing obstacle." Stool. — Cylinders of small calibre, of the size of a pencil, or of the small finger, are held to indicate a spas- modic narrowing of the lumen of the bowel. They are also seen in the stools of persons having a tendency to diarrhoea, in whom the faeces contain a superabundance of water.^ Tape-like bands denote a stricture of the rectum.^ The absence of these forms does not, however, ^jer se, exclude the existence of a stricture, spasmodic or organic. Stool in the form of scibala, hard and dry, always points to atony of the intestine. The indications afforded by color as to the presence of blood have been already mentioned. The absence of bile is indicated by the peculiar color of the stool ; it is an ashy-gray. Such stool is also very sticky, adhering like tar to the vessel and has usually a frightful odor (wanting in vegetarians). 1 Loc. cit. 2 Rosenheim, loc. cit. 8 Kelsey, Mathews, Ball. DIAGNOSIS; PROGNOSIS 127 Mucus in considerable quantity upon the stool indi- cates a hypersecretion from the rectum. Though this is frequently due to a catarrhal condition of the mucous membrane, it does not necessarily always indicate this. It may result from a temporary irritation of the muci- parous follicles produced by some transitory cause, as prolonged pressure of irritating particles in the faeces. Considerable mucus intermixed closely with the faecal matter indicates a catarrhal condition located rather higher up, in the small intestine, the caecum, the ascend- ing or transverse colon. Microscopic Examination of the Faeces/ Haematine, the coloring matter of the blood (recognized by formation of Teichmann's crystals), and crystals of hamatoidin indicate the presence of blood, and point to a haemorrhagic effusion into the bowel at a more or less early date. Pus, when recognizable, indicates the presence of an abscess, or of an ulcerative process in the intestine, or Crystals of HiEMAToroiN from F^CKS. (Jaksch.) Teichmann'i 's HjEmin Crystals. {Jaksch.) ^ See chapter " Faeces. 128 CONSTIPATION IN ADULTS the effusion of pus from an abscess exterior to it into the intestine. Pus and hcematoidin crystals point to cancerous disease. Occasionally the characteristic structural elements of this morbid process can be discovered in the fjeces. Charcot-Leyden crystals will many times denote the presence of helminthes.' Leichtenstern has found them also in the faeces of phthisical persons.^ The ova of various intestinal worms may be thus discovered. Furthermore, and of importance for the special condi- tion under consideration, such examination will disclose to us whether the person has sufficient residual matter in his aliment, or whether it is defective therein. For the better examination of the faeces both macroscopically and microscopically, the following method is recommended by Dr. Herz : A small quantity of the faeces taken from diverse portions of the stool is rubbed up in a mortar with some water. This addition of water is necessary with all stools, even with thin ones, for true watery stools are rather infre- quent, and in the former the mucous element having a specific gravity nearly like that of the corpuscular neutralizes the in- fluence of the centrifuge. A five per cent solution of carbolic acid answers very well for this purpose, as it disinfects the excrement and destroys or masks to a great extent the dis- agreeable and often nauseating odor. When thoroughly rubbed up, the mass is subjected to the action of the centrifugal ma- chine. As each of the constituent elements of the faeces has its particular specific gravity, the mass under the influence of the machine must dissolve itself into a number of separate and distinct layers. 1 Rosenheim, loc. cit. 2 Deutsche medicinische Wochenschrift, 1886. Jaksch, Klinische Diagiiostik. Microscopic Appearance of some Constipated Faeces Ji Case of Four Year's Duration I DIAGNOSIS; PROGNOSIS 129 On the surface there is a layer of turbid fluid, swarming with bacteria. Beneath this are the mighty layers of the vege- table constituent, the cellulose. Hereupon follows a black ring made up almost entirely of residual muscular fibre. Beneath this, and forming about one-eighth of the whole column, we find a number of narrow layers which contain the least numer- ous, but diagnostically the most important elements, separated from each other, as round cells, Clostridia, starch, etc. Thus already by mere inspection we may form an idea as to the composition of the fseces. For microscopic examination a portion is removed from the individual layer with a long pointed pipette. ^ When the micro-organisms are the main objects of examina- tion, the electrolytic action of the galvanic current may be employed for sedimentation, after the method of Winkler and Fisher. Two plain iron wires are connected with a battery {they worked with two carbon-zinc elements, about 200 milli- amperes) and their free ends introduced into the vessel con- taining the fluid to be sedimented. Care must be had that the free ends do not come in contact with each other and so form a short-circuit. This can be readily avoided by keeping them apart by means of a small block of wood ; even a large pledget of cotton wool will answer. Five to fifteen minutes, according to the strength of the current employed, suffice for the sedi- mentation. Under the electrolytic influence there is, as is well known, a formation of gas ; gas bubbles form a layer of froth in the neck of the flask, and beneath this is a turbid layer con- taining the micro-organisms, and from this a portion is taken up by means of a fine pipette. For' this process, the faeces are prepared as already described for the procedure of Herz. Winkler and Fisher maintain that, furthermore, amoeba are much more readily recognized, as the current stimulates them into active movement.^ For other and further details on this very interesting sub- ject, consult V. Jaksch, Klinische Diagnostik, Rosenheim, Darm- krankheiten. 1 Centrnlblatlf. innere Medicin, 1892, p. 883. 2 Centralblatlf. innere Medicin, No. 1, 1893. 180 CONSTIPATION IN ADULTS The diagnosis of idiopathic constipation having been thus arrived at, Ave will differentiate the aiojiic from the spastic form by the history and symptoms already given in preceding chapters. The atonic condition of the bowel can be demonstrated in a more positive manner, just as it is done for the stomach ; namely, by the splashing Qplaetsehern') sound. It has been found by Boas,i and confirmed by the investigations of Friedenwald,^ that in normal persons 500 to 600, and even 700 c. cm., of water must be thrown into the bowel before the splashing sound can be obtained ; while in an atonic state of the intestine the splash- ing and succussion sound can be heard after 300 to 400 c. cm. have been allowed to flow in. To bring out this phenomenon, the bowels having been pre- viously well moved, warm water (90° to 100° F.) is allowed to flow slowly into the bowel ; otherwise, if there be much force to the injection, the fluid may pass beyond the ileo-csecal valve and give rise to erroneous conclusions. At 300 c. cm. the flow is stopped and the bowel palpated ; if the splashing sound is not heard, we proceed on to 350 to 400 c. cm., and so on. In some few cases this symptom may fail us altogether, and still atony be present. As to the differentiation between acquired atony and congenital atrophy of the intestinal muscles, we must be guided by the history of the case. The constipation due to the latter condition dates from a very early period of life without any appreciable cause, as catarrh, etc., there- for. Furthermore, as has been pointed out, there is in this condition rather a slowness of discharge than a con- stipation. On the whole, however, it may be said that congenital atrophy is exceedingly rare, and cannot be clearly recognized during life. 1 Personal communication. 2 "Atony of the Intestines," Medical Neivs, August 11, 1804. DIAGNOSIS; PROGNOSIS 131 Prognosis It is not at all a question as to life. This, as has been already stated at the outset, is not endangered by constipa- tion. Exceptionally, however, and it is well to remember this, a fatal result may follow. Death has occasionally resulted from ileus paralyticus,' and I myself saw a case, already once referred to here, in which, despite appar- ent recovery from the constipation, death from asthenia, undoubtedly a consequence of the prolonged retention of fsecal matters, ensued. It is really only a question as to recovery. On this head it may be said that it is, as a rule, favorable. Al- most all cases, even when considerable dilatation or even hypertrophy of the bowel has already occurred,^ when properly managed, recover and resume a normal habit. The exceptions to the rule are these : I. Where there is a marked dislocation of the bowel of long standing, the prognosis is doubtful. II. When the abdominal walls are very flabby and re- laxed, when the belly is pendulous, so that the Bauch- presse, the pressure of the abdominal walls upon the gut, is lost, although much may be done by mechanical aids, it is, nevertheless, very doubtful whether a restoration to the normal can ever be effected. III. Old people. Here, besides atony, we have a degen- eration, resulting from age and from the prolonged atony. There are, besides, other factors, which will be mentioned further on, that tend to make the prognosis unfavorable. 1 See also James T. Goodhart, M.D., in Trans. Clinical Society, London, Vol. XIV. A case of ulceration with hypertrophy and dilatation of colon, perforation, and peritonitis. ^ See following chapter. CHAPTER XII THE CONSEQUENCES OF CONSTIPATION Though persons go through life constipated without suffering any serious derangement therefrom, it is none the less true that in many others it becomes the etiological factor, as has been well established by ample clinical observation, of various, and even very grave morbid processes. In constipation there are three prominent incidents : (a) There is an inhibition of peristalsis. (6) There is an accumulation of residual matter, and, as a result of its prolonged sojourn in the bowel, an in- spissation, and consequent hardening of the same occurs. (c) The circulation of the blood in the bowels, espe- cially the venous part thereof, is greatly furthered by the peristaltic movements, i.e. by the muscular contractions concerned therein. In constipation, however, in conse- quence of the inhibition of the peristalsis, of the distention of the bowel and the pressure upon it by the accumulated and indurated fasces, the circulation is slowed, and a turgescence or congestion occurs. The ailments which may be developed in consequence of these deviations from the normal, and which might, therefore, be looked upon as complications of constipa- tion, are : 132 THE CONSEQUENCES OF CONSTIPATION 133 1. Haemorrhoids (al^a, blood; peelv, to flow). — That hsemorrhoids may be directly due to constipation, there -V.HI YHM VHE (From Buret. Archives Gen. de MMecine, December, 1879.) Demi-schematic View of the External Surface of the Ampulla of the Rectum. Amp., Ampulla; SE., External sphincter; P, Skin of the margin of the anus dis- sected up and thrown back; VHI., Internal haemorrhoidal vein; VHM., Middle haemorrhoidal vein ; VHE. (Subcutaneous), External haemorrhoidal vein. can be no doubt. Bodenhammer ' expressed himself very clearly to this effect already at an early date, and it has been confirmed in the very recent vv^orks of Rosenheim,''^ ' Bodenhammer, Diseases of the Rectum, 1857. ^ Krankheiten des Darmes, 1893. CON-STIPATIOX IN ADULTS P III Demi-schkmatic View of the Internal Surpack of the Ampulla of the Rectum. Mq, Mucous membrane dissected up and cut away below; MCI, Muscular coat; Spi, Internal sphincter; SpE, External sphincter; P, Skin; HI, Internal hfemor- rhoidal vein; HM, Middle hfemorrhoidal vein; HE, External haemorrhoidal vein; ///, Small terminal ampullae (of the vein). The haemorrhoidal veins of the rectum, from their dependent position, and the fact that the portal system, of which they are part, has no valves and that the pres- » Traite de Medecine, Charcot, Bouchard, Brissaud, 1892, Vol. III. 2 Mathews, Diseases of the Rectum. THE CONSEQUENCES OF CONSTIPATION 135 sure therein is very small, have a natural tendency to congestion, Avhich is only obviated by the energetic peri- staltic contractions along the whole bowel, especially along the large gut. In constipation this vis a tergo is wanting. Moreover, other incidents to congestion of the rectal veins develop. The pressure of the column of the indurated faeces upon the upper portion of the rectal parietes must natu- rally tend to produce congestion and dilatation in that portion of the vessels located in the lower section. Owing to the lethargic state of the bowel and the hardened condition of the fseces, the pressure of the ab- dominal walls {Bauchpresse) will be called in to an undue extent to expel the excrementitious matter, and this will still further favor the congestion of the lower sections of the hsemorrhoidal veins. Owing to the lack of pressure from behind, the vis a tergo above mentioned, the contraction of the muscular coat of the rectum upon the vessels — the hsemorrhoidal vessels pass out through the muscular walls by small buttonhole slits which are not bordered by fibrous tissue — will tend to the production of a congestion therein and of the development of phlebectases. From constipation results the free use of purgatives, and these are important factors in the production of haemorrhoids.' II. Anal Fissure {irritable ulcer Erosions about the Anus. — This ailment, of which Van Buren^ says that it ^ Rosenheim, Kelsey, Mathews. * Van Buren, Lectures on Diseases of the Rectum. ' Loc. cit. 136 CONSTIPATION IN ADULTS is capable of causing more intolerable suffering than any other that flesh is heir to, is frequently the result of constipation. The friction caused by the passage of the indurated faeces over the very delicate integument cover- ing the anus, combined with the violent efforts of the expulsive muscles necessary for its evacuation, and the not infrequent forcible dilatation of the anus, can very readily produce the crack or fissure which constitutes this disease.^ III. Ty^mitis {Typhlitis stercoralis'^). — This is due to the distention of the caecum by the accumulating fsecal matter; the pressure produced thereby upon its walls, and the irritation caused by the induration of the mass or the presence of many irritating particles therein. IV. Appendicitis. — I hold that this very grave affec- tion is in the majority of cases provoked by constipation (temporary or habitual). It seems to me more than demonstrated by the fact that in the greater part of the cases the materies peccans found in the appendix is ftecal matter. Thus, Symonds^ found that in twenty-three fatal cases of appendicitis there were faecal concretions in twenty-two, and a foreign body, a grain of wheat, only in one. Matterstock * found faecal concretions in fifty-three per cent of his one hundred and sixty-nine collected cases. Fitz,^ in one hundred and fifty-two cases of perforated appendicitis, found faecal masses in forty-seven per cent. 1 Bodenhammer, On Anal Fissure. Van Buren, loc. cii 2 Henoch, Unterleibskraiikheiten. 8 British Medical Journal, December 19, 188.5. * Gerhard, Hdb. der Kinderkrankh., IV. 6 Transactions Assoc. of American Physicians, Vol. I., 1886. THE CONSEQUENCES OF CONSTIPATION 137 Kelynack," who has studied this subject, says : "There can be no doubt but that far and away the most frequent abnormal contents of the appendix are hardened faecal masses, which are frequently infiltrated with lime salts, forinms; distinct concretions." At a late meeting of the pathological section of the Academy of Medicine (New York),- a similar opinion as to the predominance of faecal accumulations in the ap- pendix was expressed by the gentlemen present. From my standpoint, it can be readily understood why this should be so. The frequency of the disease is also explained. In constipation, the residual matter accumu- lates in the caecum and distends it ; the opening leading into the appendix is thereby enlarged.*^ Faeces can now pass into the appendix, or rather are driven into it by the constantly growing mass. Their return, however, into the csecum is prevented by this same mass of faecal matter, which acts as an obstructing wall against any- thing coming from the appendix, and by lack of suffi- ciently powerful muscular effort. This faecal matter in the appendix, becoming inspissated and indurated, acts as an irritant and develops the pathological conditions that constitute appendicitis. The statement of Fenwick"^ that out of forty-three cases of perforative appendicitis, where the previous state of health has been recorded, he had found that only in three instances had there been any definitive constipated 1 Kelynack, A Contribution to the Pathol, of the Vermiform Appendix, 1893. 2 Meeting in April, 1895. ' See case of Morris Price on p. 148. * Clinical Lectures on Obscure Diseases of the Abdomen, 1889. 138 CONSTIPATION IN ADULTS state of the bowels, does not detract from the force of my argument. My experience has taught me that many more persons are constipated than really have an idea that they are so. With some, the evacuation, every morning, of a few hard, rocky scibala, requiring con- siderable effort for their expulsion ; with others, a scant evacuation even every third or fourth day, — is held as evidence of regularity, and they will tell their physician, when the occasion arises, that their bowels are regular. Furthermore, attacks of temporary constipation are en- tirely overlooked or forgotten by the great majority of people. This point, the etiology of this disease, I hold of the greatest importance, both as to the therapeutics in the early periods of such cases, and the prophylaxis of perforation. V. Enteritis Membranacea {Membranous ententis). — Lit- ten ' maintains that constipation is, in very many cases, the cause of this very troublesome affection. VI. Proctitis may result.^ A very remarkable case of sloughing of the rectum as a consequence of faecal impaction is reported by Dr. W. M. A. Wright.'^ Case 15. The patient, a lady aged sixty-five, who had had piles for the last twenty years but who was in other respects quite healthy, who led an active outdoor life and whose bowels were stated to have always acted most regularly, became ill on January 22, 1884. When visited on the following day, she said her piles had become inflamed, and on examination a ring of them was found external to the anus, nipped by the sphmcter, 1 Berliner klinische Wochenschrift, 1888, No. 29. 2 Mathews, loc. cit. 8 Lancet (London), June 6, 1885. THE CONSEQUENCES OF CONSTIPATION 139 congested, veiy tender, and irreducible. Anodyne treatment was adopted locally and generally. On the 25th profuse leu- corrhoea set in and on the 27th complete retention of urine, which lasted for eight days. On the 28th diarrhoea came on, and the skin over the gluteus maximus on both sides of the anus, but especially on the right, became very tense, red, glazed, and erysipelatous-looking. On February 1 an external opening formed on the right side, about an inch from the anus, and almost all the faeces began to pass through it ; by the 4th power over the bladder was regained and the inflammation had sufficiently subsided to allow of a rectal examination, when an enormous mass of fseces was found, broken up by the finger, and partially removed by an enema ; daily enemata removed the entire mass by the 10th. When the ffecal tumor was par- tially got rid of, the internal opening was made out clearly about one inch and a half up the gut on the right side, and as large as a half-crown piece. On the 14th a secondary abscess, with odorless pus, opened into the fistula, after which recovery was uninterrupted. Dr. Wright remarked that the inflammation of the piles and the sloughing of the rectum were undoubtedly caused by the pressure of the fsecal mass (just as a foetal head may cause sloughing of the vagina in the second stage of a tedious labor) ; the periproctitis and erysipeloid condition of the skin over the buttock was caused by the escape of the faeces into the cellular tissue of the ischio-rectal fossa. VII. Faecal Tumors (Koth tumoren)^ Concretions, Entero- liths.— By reason of the lethargy of the bowels, and the consequent stagnation of faeces, collections of it m^y form in one part of the gut or another, and which, taking on diverse shapes and forms, are frequently mistaken for dislocated organs, usually for wandering kidney, or for abnormal growths, or for abscesses, and errors, therefore, made in the diagnosis, prognosis, and, what is worse, in the treatment. 140 CONSTIPATION IN ADULTS Case 16. Fcecal tumor mistaken for a nephritis, later on for an abscess. (Archives Generales de Medecine, T. XX., 1829 p. 581.) Lanvin, cet. twenty-five, joiner, of sanguine temperament, called Dr. Duces on July 24, 1828. He had an attack of acute nephritis, characterized by great pain in the region of the right flank, which travelled down the length of the ureter into the bladder. Painful retraction of the testicle of the affected side ; moderate thirst ; urine red ; fever slight (leeches, calming po- tions). . . . 26th. All the symptoms on the part of the bladder have disappeared and the renal pain is greatly diminished. The patient not having had an evacuation for four or five days already prior to the attack, and the digestive organs presenting no point of inflammation. Dr. D. prescribed Ole. Ricini 5i- This was rejected by emesis . . . gastritis; delirium (leeches, gum water). . . . 28th. The night was fairly quiet ; the gastritis has disappeared ; the pain in the flank always of the same intensity ; tumefaction in this region ; the belly in the rest of its extent is supple (purgative injection). He has had several stools, and, in consequence thereof, some loose- ness, which lasted for several days. . . . 29th. Consultation ; thirty leeches on tumor, which has grown steadily. Belly always supple. . . . August 2d. Condition unchanged, tumor continues to grow (thirty leeches, poultices over tumor). . . . 6th. Same condition of tumor ; the centre somewhat fluctuat- ing; it seems certain that an opening into it will have to be made. Before proceeding to make this opening. Dr. Dar- donville proposed the administration of a laxative, that he might assure himself that the intestinal canal was perfectly free throughout its whole extent, so that in case the abscess broke into the bowels, the purident fluid would have a free course. (Ole. Ricini 5i, Syr. Alth. 5i, Syr. Caryophylli Ruhr. 5i.) The patient took this mixture in tablespoonful doses throughout the day and evening ; in the course of the night he had abundant alvine discharges, hard and of grayish color. On the following morning the tumor had almost entirely dis- appeared. In one word, the patient was cured ; not a trace of the abscess existed any more. THE CONSEQUENCES OF CONSTIPATION 141 Four cases are reported by Bright.' Case 17. Accumulation offceces in the sigmoid flexxire of the colon, imitating organic tumor. August 1, 1840, I was requested to see a young gentleman who had been brought to town a few days before, convalescent from a severe attack of purpura followed by extensive pleuro- pneumonia. He had been seized in the night with bilious vomiting, great prostration with writhing pain in the abdomen. The pulse was frequent and small, the countenance sunk and pallid, and I found considerable tenderness on pressure ; there had been but one small motion the day before and another that morning, but I could see neither. The first idea which sug- gested itself was of some severe obstruction of the bowels, or hernia amongst other causes. I inquired for any pain towards the groin, and on placing my hand low down in the left iliac region, not far from the internal ring, I felt a distinct tumor. The part of the abdomen between that and the margin of the ribs on the same side was more tender than any other, and somewhat tense. I naturally felt uneasy lest some mechanical or organic cause should exist. The tumor was more diffuse than any ordinary hernial protrusion and yet its more promi- nent part felt circumscribed ; it did not dilate on coughing. A poultice was applied over the left side of the abdomen, and two grains of calomel with half a grain of opium were ordered ; effervescent draughts with excess of alkali were given to allay the sickness, and a large injection of soap dissolved in water was thrown up. These remedies having been repeated two or three times, we procured before night a feculent evacuation of solid lumps, and the tumor in the iliac region was quite removed and all the symptoms subsided. Case 18. Fcecal accumulation in the colon, imitating malig- nant disease of the liver. A. B., a seafaring man aged about fifty-five, was admitted into Guy's Hospital under my care, with a hard lobulated 1 Guy's Hospital Reports, Vol. V., p. 302. 142 CONSTIPATION IN ADULTS tumor, about midway between the point of the ensiform car- tihage and the umbilicus, in which he suffered considerable pain, both from pressure and without it. His complexion was sallow; his bowels stated to be freely open. After a careful examina- tion, I felt very little doubt that the tumor was organic and connected with the left lobe of the liver, nor did the effect of the remedies or the appearance of the patient at all undeceive me for some weeks ; but I presently began to suspect that the pains of which he made such frequent complaint were rather of a spasmodic character, and such as indicated some detention of feeces in the intestine. I therefore put him on a more de- cided plan of purging than at first, though the bowels had never been neglected. He now took repeated doses of comp. extract of colcynth, galbanum pill, blue pill, and small quan- tities of muriate of morphia. The effect was, after a few days, to bring away a quantity of hardened balls of faeces, and in proportion to diminish the supposed malignant tumor, till both pain and morbid growth and every other symptom of disease had disappeared. In diseases of the liver with disturbed biliary secretion, such lumping together of faeces, more particularly in the rectum, is not rare. The following very interesting case was communicated to me by Dr. Arthur Kahn, of this city : Case 19. Fcecal accumulation mistaken for wandering kidney, for tumor of the liver, for a growth connected with the genital tract. Mrs. R. E., aged forty-one years ; married; has three chil- dren. Since three years she has on her right side, about three inches from the umbilicus, a palpable tumor, which has grown but very slowly. She consulted a number of physicians, there- fore, and different opinions were expressed as to the organs with which it was connected. It was regarded by some as a wandering kidney, by others as a tumor of the liver, and still others regarded it as connected with the genital tract, and pro- posed an operation for its removal. This was declined. THE CONSEQUENCES OF CONSTIPATION 143 After the lapse of the time mentioned she came to me for treatment. General history as above given. Present condi- tion : she is obstinately constipated. This constipation dates far back, and is becoming more and more obstinate. The stools cause her great pain, and the fteces come out in hard lumps and pieces unless immense quantities of vrater are frequently injected. There is a feeling of fulness in the right hypo- ehondrium, just above the tumor. Sometimes ructus. After eating the feeling of fulness and of oppression is very pro- nounced. Above the tumor and outward there is a circum- scribed painful zone. Patient is very nervous and very irritable. Otherwise in good condition, rather vigorous, with a good panniculus. Since four days patient has been troubled with an unceasing desire to go to stool, with severe colicky pains, without suffi- cient discharge. The abdomen is somewhat distended; the walls rather tense. She has been taking opiates without, how- ever, being in any way benefited : the pains have become more violent, almost intolerable. The tumor is located in the region already described, on a direct line with the umbilicus ; is of the size of a man's fist and rather knobbish. An examination of the abdomen showed that the tumor was rather round than oval, and was further removed from the costal arch than would be the case with movable kidney. The urine varied but little in quantity. The borders of the liver could be well defined, and it was shown that the tumor was entirely independent of this organ. As to its connection with the ovaries or uterus, this could not be demonstrated with any certainty. I prescribed large doses of podophyllin (0.02 pro dosi) with strychnine and hyoscyamus (aa 0.0015) and belladonna (0.006) every three hours, until an effect was produced. I also ordered Avarm baths, abdominal pack, massage. After seven hours of great suffering, so severe that the patient fainted several times, she had several evacuations and discharged more than half a bucketful of faeces. In this she found a thick ball, which so 144 CONSTIPATION IN ADULTS distinguished itself by its size, its color, and its hardness that It attracted her attention. It was so hard that it was broken up only with considerable difficulty by the use of a poker. In the evening I found the patient well, but somewhat weak. Two months thereafter the tumor reappeared, but under the use of purgatives again vanished. It manifested itself again nine months thereafter, and the same treatment had the same happy result. I have not seen the patient since. These tumors are formed by the accumulation of fseces around a foreign body, — chaff of grain, stone of fruit, seed, piece of bone, etc. ; sometimes a particularly hard portion of fseces forms the nucleus for further accretions. Very frequently the tumors become incrusted by the deposition of salts upon them, and then present varying degrees of hardness to the touch.' Case 20. An intestinal concretion^ the surface of tvhich tvas covered with long prismatic crystals of triple phosphate. Dr. Hector W. G. Mackenzie (Transactions Pathol. Society, Lon- don, Vol. XLIII.). A woman aged seventy, who had been a sufferer for many years from constipation, took a large dose of salts to relieve her bowels, which had not been opened for some days. When the bowels were moved, she was much alarmed at finding what felt like a hard bony mass presenting itself at the anal orifice. This, as afterwards turned out, was a concretion ; but she imagined at the time that part of her body, perhaps her back- bone, was coming away, and she made every effort to retain it in its position. She succeeded in putting it back into the rectum, where it remained for four months, at last coming away one day in spite of her. At the time it was voided some 1 Leichtenstern, Ziemssen's Cyclopsedia, Vol. VII. Rosenheim, loc. cit. THE CONSEQUENCES OF CONSTIPATION 145 of it was broken ofP, so that originally it was larger than it now is. It is about the size of the astragalus, and weighs 497 grains. . . . Dr. Bernays has very kindly submitted the speci- men to chemical examination, and has reported that the crys- tals consist of ammonio-magnesian phosphate, with a trace of organic material. The mass may become permeated with mineral matter, petrified, in fact, and form an enterolith. Case 21. Removal of an enterolith, etc. Dr. Sab in (Trans- actions of the N. Y. State Medical Association, Vol. II.). On September 1, 1884, my father and myself were called to see Miss L., aged thirty -five years, who was pale, thin in flesh, — almost a skeleton, — and looked careworn and weary. She said that she was twice mechanically relieved, years ago, of impacted fseces by the breaking down and removal of the masses ; that she had much pain in the rectum, and was in general a great sufferer ; but although she believed that her condition was substantially the same, she would not consent to even a digital examination without ether. During the nar- cosis I found a hard mass, as large as a turkey's egg, not capa- ble of receiving any impression from the finger. ... At the appointed time on the succeeding day I again administered ether, of which a very large quantity was used. The opera- tion, which consisted of dilating the sphincter, and crushing the stone with strong forceps and removing it in pieces, lasted an hour and ten minutes. . . . An attempt was made to get it away whole, but on account of the brittle nature of the shell it broke, which very much facilitated its removal. The mass that was removed weighed 41 ounces, more than half an ounce having been lost by crumbling. This mass, on close examina- tion, was seen to consist of petrified fa3ces. According to the patient's statement, it must have been forming from fifteen to seventeen years; still it had never given her trouble until within a few weeks past. She would often take laxative medi- cine, which would produce stools, but she could not say that 4 146 CONSTIPATION IN ADULTS she had ever felt relieved. I had the specimen of stone ana- lyzed by Professor W. P. Mason, M.D. He reports the compo- sition as follows : Organic matter, phosphate of lime, phosphate of magnesia, carbonate of lime, sulphate of lime, silica a trace. The main constituent is phosphate of lime. Owing to the imperfect depuration, or rather want of depuration of the digestive tract, foreign matters, both vegetable and mineral, are allowed to collect therein, together with the f^ces, into a mass, and form concretions or enteroliths, which may reach great size. Moreover, by reason of the slowness of movement, and consequent long retention, deposits may occur from the natural secretions of the body, and thus give rise to the formation of an intestinal stone. Case 22. Concretion, consisting mainly of the chaff of oats. Turner reports the case of a man who suffered from obstinate constipation ; had already some years before passed two or three bullet-like lumps, and since then had a continual uneasy and annoying sensation in the left side. After four days of absolute constipation. Turner found the abdomen very sensitive and detected in the epigastric and umbilical regions a large, round, hard, and but slightly movable tumor. He regarded it as a scirrhus. Eight days later the tumor began to descend, to the great relief and comfort of the patient ; very soon it could be felt in the rectum by the introduced finger, and was quickly extracted. It was found to be a concretion made up chiefly of the chaff of oats, and was about twice the size of a billiard ball. Later on thirteen more such concretions, ranging in size from a pigeon to a hen's egg followed. Thereupon the patient was completely relieved. ^ 1 Edinburgh Montlihj Journal, 1841. Quoted from Henoch, Die Unter- leibskrankheiten. Other similar instances are reported by Pereira, Food and Diet. Third Edition. (Article " Oats.") THE CONSEQUENCES OF CONSTIPATION 147 Case 23. Enormous concretion of iron and magnesia, removed by operation from the lower bowel. Reported by J onathan Hutch- inson (Transactions Pathological Society, London, Vol. VI.). A lady past middle age consulted Mr. Lacy, in May, 1853, with the account that she had, for more than twelve years, suffered extremely from constipation, and most painful sensa- tions in the lower bowel. . . . On passing the finger into the bowel, a hard uneven sub- stance was encountered, having somewhat the shape of a vase and being at least fifteen inches in circumference. Its exterior did not in the least resemble indurated faeces, feeling indeed as hard as a stone and being rough like an oyster. Very fortu- nately its interior was not so hard as the outside, otherwise its removal might have been impracticable. By the use of a pair of long polypus forceps a hole was gradually made into its centre, and working outwards from this by degrees the mass was broken down and extracted piecemeal by means of a scoop. Many sittings were, however, required before this result was obtained. . . . The outer part of the concretion consisted of concentric layers of what looked like a red stone, and which proved on examination to be a compound of iron and magnesia. The interior was softer, — a mixture of the earthy and ferrugi- nous matters with many thousands of strawberry and other seeds. . . . Nearly thirty years ago the patient had been in the habit of taking carbonate of magnesia very frequently, in large doses, for the relief of stomach irritation and had also, about the same time, used the sesquioxide of iron very freely during attacks of tic-douloureux. It was from shortly after this period that her first symptoms of intestinal irritation dated. For twelve years past she had never taken either of the drugs named. The following interesting case was reported in the daily press, Baltimore AmerioMn, and copied in the Cincinnati Enquirer, September, 1895. 148 CONSTIPATION IN ADULTS Case 24. Ihe operation of laparotomy performed on Jere HoUinger, near Greencastle, Franklin County, resulted in the discovery of a hard ball of sawdust. Mr. Hollinger, while building a house often chewed a chip, particles of which he swallowed, forming the ball. A very interesting case of intestinal calculus of almost pure cholesterine has already been given at tlie outset (see page 61). * To what an enormous extent faeces may accumulate in the bowels, and still the patient not be aware that he is constipated, is very well shown by the following history reported by Morris Price, L.R.C.P.:^ Case 25. In August, 1877, I was consulted by a young lady, aged twenty-four, who complained of symptoms of indi- gestion, occasional vomiting, etc. ... A week later being no better I asked her to undress, that I might properly examine her. To my astonishment I found that she had large, nodu- lated, firm, painless, movable tumors, occupying the lower part (and chiefly the left side) of the abdominal cavity. There was no gastric tenderness, menstruation had been regular, the bowels were being moved, in fact there existed a spurious kind of diarrhoea.^ I considered it advisable at once to examine the rectum, when I found that this was tremendously distended and packed full of dry, nodulated, earthy fsecal matters, the anus being in a continual state of patency, due to the paralysis . of the sphincter by mechanical distention. So much was the rectum distended that a child at full period could easily have passed through it. . . . This individual, when a child, was in the Denbigh Infirmary, under the care, I believe, of Dr. Tur- nour, for accumulation in the bowels. Getting the patient to the edge of the bed covered with a sheet of oilcloth and using plenty of soaped warm water, I 1 British Medical Journal, 1886, II., 1211. » Italics mine, Illoway. THE CONSEQUENCES OF CONSTIPATION 149 diligently dug away at this mass with my finger (which I think better and safer than a spoon) for a considerable length of time, finding that the mass was gradually descending as it was removed below. Suffice it to say that in this way the whole mass in the colon and rectum were cleared. *********** Eighteen months afterwards I was called to her again. This time I found her just in the same state ; applied the same treatment, but not with the same success, inasmuch as a mass was left in the sigmoid flexure of the colon which would not descend into the pelvis. This could easily be felt by intro- ducing a long tube against which the point would impinge, but which would give way under a little pressure. Injections were of no avail, coming out as administered, owing to the compact- ness of the mass. After this attempt to clean the bowels, symptoms of complete obstruction supervened, as evidenced by her vomiting every meal she took, as well as a stoppage of any f fecal discharge from her bowels. These symptoms were not accompanied by any greater dis- tention or tenderness of the abdomen, neither was there any additional pain ; and in spite of the administration of various kinds of purgatives and medicines, as well as enemas, they con- tinued for several weeks. . . . While she was away an idea on one occasion suggested itself to my mind of doing something for her. The idea^was to introduce my hand into the gut and to push it up as far as possible with the intention of getting out and removing the obstruction. ... I operated with the assistance of my old master, Dr. Davies of Llanfair, Talhaiarn, and Dr. Roberts. My intention was to dilate the anus, but finding this impracticable, under chloroform I divided the whole structures back to the coccyx. Now I could easily pass my hand, and Dr. Roberts passed a long tube in by my wrist, through which warm soaped water was injected. At the top of the pelvis I came across the big mass which I had so often felt and vainly attempted to remove, but now I could easily crush it. The arm was now withdrawn, when the whole mass was expelled. After reintroducing the arm, I found that the 150 CONSTIPATION IN ADULTS colon was in a very abnormal condition, because, instead of there being an ascending, transverse, and descending colon, it was one tremendously distended chamher^ and with my whole arm introduced up to the axilla, I could, on account of her great emaciation, investigate and manipulate every part of the abdominal cavity with the other hand externally. Strange to say, in the neighborhood of the right iliac fossa I found an opening of an oval shape large enough to allow the passage of a good-sized plum (an inch and a half long) with a well-defined margin. This was plugged with a lump of hard faecal matter, which was removed and crushed in the large amount of water which had by this time been injected. Every part was now thoroughly examined, and after satisfying myself that there could be nothing more the arm was withdrawn. Sutures were carefully inserted, a soft catheter placed in the bladder, and by and by a large dose of opium was given. . . . After this she got up, gradually resumed her ordinary diet, and I took care to watch her carefully for some time with the satisfaction to find that the bowels gradually resumed their normal functions without the use of aperients or enemas : the bowel no doubt, as time went on, in spite of the extraordinary distention, resuming its tone and contractile power ; while the inestimable advantage of a sphincter capable of discharging its functions, has been regained. In this way the patient has kept for over seven years. Lastly, what the above opening was, unless it was the ileo-csecal valve, I am al a loss to know. VIII. Dilatation. — Accumulation of faeces leads to dis- tention and to dilatation of the gut. The dilatation may be general, involving the whole large bowel from the caicum to the anus, as in the case above recited, or par- tial, affecting a certain section of the gut only. Haberslion'' has reported a number of cases of marked dilatation of the caecum. He has seen cases in which the 1 Italics mine, Illoway. 2 Habershon, Diseases of the Abdomen, 3d edition, p. THE CONSEQUENCES OF CONSTIPATION 151 colon was so enlarged as to measure twelve to fifteen inches in circumference. The sigmoid flexure may be the part dilated. Case 26. Idiopathic dilatation of the large intestine. Samuel Gee.i A boy came under my notice when he was four and a half years old. When he was three months old he began to have difficulty in passing his motions, which were hard. His belly began to swell when he was twelve months old, and afterwards it became continuously bigger. When I first saw him he was thin. His abdomen was very large; everywhere resonant to percussion ; what looked like coils of intestine were distinctly seen ; the tension of the abdomen and the dyspnoea were very great. His bowels had not acted for two days, and an enema of warm water was given. Fifteen minutes afterwards he passed a large quantity of very dark, loose fseces, smelling badly. The same evening he began to vomit; he thrice vomited large quantities of sour brownish liquid not stercoral in smell or look. In short he seemed threatened with ileus. Next day I passed a long tube up his rectum as far as it would go, and so let ofE a little loose, slaty colored, stool and a very great quantity of wind. His belly became much smaller and softer. The vomiting ceased. Appetite for food returned. He was able to lie down. After this I tried diverse means to get his bowels to contract ; namely, cold douches to the belly, friction with stimulating liniment, passage of a tube twice a day, and careful bandaging of the abdomen. But to no avail. The child became thinner, and after ten days I desisted. He seemed much as usual until about a fortnight afterwards the urine was observed for the first time to be bloody; it had been examined several times before and found to be natural. He quickly became worse : very abundant watery diarrhoea set in and he died two days afterwards. When the belly was opened after death, nothing was to be 1 St. Bartholomew's Hospital Reports, 1884, XX. 19. 152 CONSTIPATION IN ADULTS seen therein save two great pieces of intestine, which were the sigmoid flexure hugely distended. It formed two sacs which lay side by side, one sac filling up the right half of the belly and the other the left. Tlie anus led into the lower end of the right sac, which passed upwards and opened under the dia- phragm into the upper end of the left sac by a short strait of narrower bowel, whence there was a descent into the left half of the sigmoid as hugely distended as the right. This descend- ing sigmoid sac led, in the left iliac fossa, into the lower end of the descending colon. The colon was quite natural, both in size and position, and lay hidden behind the enormous sigmoid flexure, caecum, and small intestine. Diameter of widest part of sigmoid was about four inches, its muscular coat and nerves were greatly hypertrophied. The liver was much pushed back ; structure of both liver and spleen natural. Kidneys very hard,, quite like the kidneys of dilated heart ; cortical structures dis- tinct, veins dilated. Pelves of kidneys were much dilated ; ureters also ; in right ureter was a hsemorrhagic ulcerated ring, coated with uric acid. The condition of the kidneys and ureters was probably due to pressure. . . . At present for want of a better explanation I think that mere constipation and retention of wind are the cause of the dilatation. Case 27. A case of so-called idiopathic dilatation of the colon. By Angel Money and Stephen Paget. The patient was first seen by Mr. Paget on September 13, suffering from enormous distention ; he measured sixty inches round, and twenty-six from the ensiform cartilage to the pubes. The whole abdomen was evenly distended, globular, extremely tense, and resonant or even tympanitic ; there was no pain or tenderness, no movement or gurgling. The condition of his lungs was most alarming ; nothing was heard but loud mucous rales ; he was very livid, and his breathing was quick and shal- low. He just could stand or walk a few steps with support. His history was as follows : He was fifty-five years old, and for the last five years had been living alone, drinking inces- santly both beer and spirits. The distention had been coming THE CONSEQUENCES OF CONSTIPATION 153 on for some months, but had become worse rapidly during the last week. He had all the aspects of an habitual drunkard, — the typical nose and face, the arteries very tortuous and rigid, the legs oedematous, the urine high colored, 1022, albuminous. His bowels had always acted regularly, though lately they had been somewhat constipated ; they had acted freely the day before. *********** At the necropsy the enormous distention was still found to be present, and to be clearly due to dilatation of the colon. But it was not simply a uniform or moderate distention of every part of the colon ; the dilatation of the sigmoid flexure took the lion's share in the enlargement, there being two large sacs, each far bigger than any ordinary dilated stomach ; and these two sacs alone would have been sufficient to have caused a distention second only in degree to that distention from which the patient suffered. The contents of these great sacs and of the rest of the dilated colon were chiefly a light brown, pultaceous, fermenting, and semifluid substance which had the consistence of ordinary gruel. In addition to this semisolid stuff there were accumu- lations of gas and of fluid ; and, strange to say, at the hepatic flexure of the colon, which was not nearly so dilated as the rest of the large bowel, there was a big scibalous mass which pre- sented in its stony hardness a curious contrast with the pulta- ceous substance already mentioned. *********** In addition to the dilatation of the cavity of the colon there was also considerable hypertrophy of its walls, which was espe- cially evident in the three longitudinal muscular bands, but existed in the circular fibres also.^ Despite the statement in the history, it is very clearly evident that the patient must have had periods of long and obstinate constipation with much accumulation of 1 Transactions Clinical Society, London, Vol. XXT. 154 CONSTIPATION IN ADULTS faeces and gas. This (with the alcoholic habits of the patient) readily explains the dilatation, and demonstrates it to be not an idiopathic, but a secondary, dilatation, a consequence of constipation. *********** When the sigmoid flexure is filled with accumulated indurated faeces it may be drawn downwards into the pelvis by the weight of the mass. By this sinking down, the upj)ermost portion of the rectum is bent upon itself, and thus all communication between it and the sigmoid flexure shut off. Furthermore it compresses the rectum, and thus effects an obstruction. When this has occurred, there will be found on exami- nation of the rectum upon its anterior wall a protuber- ance hard and knotty, which with a little manipulation can be pushed upwards and out of the pelvis. In females an examination per vaginam will disclose the tumor press- ing upon the posterior vaginal wall, and possessing the characteristics described. The following observation of Asmus ^ is very character- istic : Case 28. A young girl, twenty-five years of age, became ob- stinately constipated by opiates, which she had taken for the relief of violent toothache. The remedies ordered provoked stools, but never to the satisfaction of the patient, who always felt as if there was still more to be evacuated. Very soon the belly became distended, the discharges smaller and smaller, and she had violent colics. Medicines and clysters were without avail ; the latter were even painful, and but a few drachms of fseces would be brought away in the course of several days. At the end of half a year the pains were unceasing, and robbed 1 Casper's Wochenschrift, 1834, p. 166. Quoted from Henoch, loc. cit. THE CONSEQUEJfCES OF CONSTIPATION 155 the patient of sleep. She became emaciated, had anorexia, vomiting, dysuria, a heaviness of the pelvis, and a constant feeling as if she must go to stool. But she had no stool, not even flatus passed. The rectum being examined a tumor was found located upon the anterior wall of the rectum, which it pushed back upon the posterior wall, and thus mechanically shut off all communication between the parts above and those below. The tumor was very tense, of stony hardness, immov- able, and on pressure excited a desire to go to stool. Guided by this last feature large doses of Ole. Ricini were ordered, and efforts made during the process of defecation to push the tumor upwards and forwards with the finger introduced into the rectum. In three days incredible masses of scybala, hard like stone, were passed, whereupon the tumor entirely dis- appeared. The rectum may become an enormous pouch. In the case reported by Dr. I. T. Goodhart of " ulceration with hypertrophy, etc., of the colon," the rectum laid open and measured from one cut edge to another gave a circumfer- ence of seventeen inches. Case 29. Dr. Revillout, service of Professor Vulpian. (la- zette d. Hopitaux, 1877, No. 75. A man aged forty was admitted to the Charite, ward Saint- Jean de Dieu, No. 1. He had an enormous belly which pre- sented two distinct zones on percussion ; there was found on the inferior section of the abdomen, on the declivity, and when the patient was made to change his position, always up to the same level, a very apparent dulness, corresponding to a mani- fest fluctuation; in the superior section, on the contrary, a tympanitic resonance is heard. The intra-abdominal return circulation was evidently very much disturbed, for all the superficial veins, both of the thorax and of the abdomen, stood out prominently, markedly devel- oped, so as to permit of a very active supplementary venous circulation. The first impression that was made by these phe- 156 CONSTIPATION IN ADULTS nomena was that this was a case of atrophic cirrhosis of the liver, with embarrassment of the portal circulation leading to ascites and to engorgement of the superficial veins and to some oedema of tlie lower extremities. This diagnosis once made, nothing occurred to contradict it. . . . Questioned as to his histor}'-, he stated that at his birth he had an imperforate anus ; an operation which was successful was made, and for seven years thereafter he was compelled to wear a canula in the artificially made anus. He attached no importance to this, however ; he lived as do other persons, married, and became the father of a family. Nevertheless he always felt some em- barrassment at stool ; the evacuations were not free, and it required much effort to discharge a minimal quantity of fteces. In tills last period when he came to regard himself as seriously sick, he was often seized with paroxysms of suffocation ; he could not breathe ; he felt himself choking, and made unheard of efforts to unload his belly, and when he succeeded in dis- charging a little flatus he felt relieved. In the intervals between the paroxysms he was fairly well. *********** At the autopsy, in place of the cirrhotic liver which was ex- pected, there was found an extraordinary dilatation of the sig- moid flexure and of the rectum. These two sections of the large bowel formed an enormous pouch, which gave forth a loud noise when the scalpel was pushed into it and allowed the escape of a quantity of gas and of feecal matter. Measured the following day, and although already considerably con- tracted, the pouch was 90 cm. long, at least, and 70 cm. in circumference at its middle. The anus was found very narrow and drawn together on all sides by a very resistant cicatricial tissue. The point of the finger could barely be made to pene- trate. Immediately above the obstacle the dilatation began. There was this peculiarity about the dilatation, that the pari- etes, far from being distended and thinned, as would be sup- posed, were hypertrophied and fortified in all their constituent tissues. The muscular and mucous coats were increased five- fold in power. The whole intestinal wall had a thickness of THE CONSEQUENCES OF CONSTIPATION 157 about one-half cm. ; there were seen on the internal surface glands equally enlarged and groups of follicles much more prominent than is usually the case. *********** The amjoulla of the rectum alone may become largely dilated.' As in other organs, so also in the intestines dilatation may be attended by hypertrophy. It is mentioned as hav- ing been observed in the cases of Gee and Revillout, and the following cases are still further and marked illustrations : Case 30. A case of ulceration with hypertrophy and dilatation of colon., perforation^ and peritonitis. Dr. James T. Goodhart. (Transactions Clinical Society, Vol. XIV.) Emma R., cet. seventeen, was admitted into the clinical ward of Guy's Hospital. Her father is dead; the cause of his death is unknown. Her mother is still a healthy woman. One brother died of rheumatic fever. The patient has always had delicate health ; has never had rheumatism. In Decem- ber, 1879, her usual health began to fail, but she had no defi- nite symptoms — no especial pain. Her abdomen has been gradually increasing in size since January of the present year (1880), but more rapidly in the last month, and she has been worse for three weeks in her general health. She has never had severe pain in the abdomen, but has had slight sudden pain at times. The bowels have been irregular since January — since, that is to say, the onset of the abdominal swelling. Sometimes she has had constipation, at others diarrhoea. For the last three weeks the latter state has existed ; the bowels acting seven or eight times a day, the motions being offensive, blackish in color, and for three weeks she has been unable to retain her motions. The action of the bowels has caused no pain. When admitted she was remarkably anaemic, spare ; 1 See Chapter XXII., " Atony of the Rectum." 158 CONSTIPATION IN ADULTS she was so bloodless as to suggest that she had lost blood from some source. She had an anxious expression ; pulse 128 and the abdomen was much distended. It was at first thought by the clinical clerk that some abdominal tumor was present, and certainly on first placing the hand on the abdomen the case had that appearance, for a large, very hard mass was felt to occupy the right side from the iliac region to the hypochon- drium. But on a more prolonged palpation the tumor dis- appeared, to be succeeded by the occurrence of one in the epigastrium or left Uiac region. Moreover, there was reso- nance all over the abdomen, and on inspection the intestine could be seen in peristaltic action. The umbilicus was dis- tended, but there was no thrill. The abdomen was not tender, and there was no evidence of any enlargement of liver or spleen. . . . Post-mortem Examination. — The abdomen was enormously distended and tympanitic. On throwing back the abdominal parietes and exposing the intestine, the colon was seen to be greatly dilated and occupying the entire front of the cavity. The sigmoid flexure occupied the right iliac fossa, having pushed the caecum, which was not enlarged, backwards and inwards. Tracing the bowel from the ileum along the ascend- ing colon, it was found that the large intestine suddenly dilated about the hepatic flexure. Below this point it became wider and wider, so that the rectum formed a lai-ge cylinder. The dilated part contained a large quantity of black pultaceous mat- ter without scibala, and some of this was exuding into the peri- toneum from a small perforation in the sigmoid flexure. The peritoneum contained some very foul gas and a small quantity of purulent fluid. The dilated colon, particularly its lower part, was almost cartilaginous in its toughness, and was hyper- tropJiied to about one-sixth of an inch in thickness. On laying it open two superficial ulcers were found close to the anus, each the size of half a crown, and more or less oval in shape ; a little higher up were two others, and in the sigmoid flexure was a large one with sinous margins in the middle of which was a small, sloughy patch, with a central perforation previously de- THE CONSEQUENCES OF CONSTIPATION 159 scribed. Higher up still the mucous membrane was reddened in several places, and here and there was an erosion. All the ulcers presented similar characteristics ; the mucous membrane was destroyed, leaving the muscular fibres exposed ; the sur- faces were smooth, the edges were thickened and rounded. The remainder of the bowel, small intestine, and stomach were healthy and contained little fseces or food. There was no stricture of the rectum or anus and no fissures. The uterus, ovaries, liver, spleen, and kidneys were all healthy. Case 31. Dr. E. F. Walsh in the Northwestern Lancet, Vol. XIII., reports the case of a child aged eight years, in whom great distention of the gut with hypertrophy of the muscular coat were found. The bowel measured from the caecum to the rectum nine to ten and a half inches in circumference. The Tiypertrophy of the colon was marked, being greater in the sig- moid flexure, where it measured one-eighth of an inch in diameter. As in the heart, this hypertrophy is the effort of nature to counteract the effect of the dilatation. Copland, quoted by Habershon,^ mentions cedema of the right leg produced by a distended and overfilled CEecum. This is due to pressure upon the iliac veins. The oedema may be about the ankles. A tendency to varicocele has also been observed as a result of mechanical hindrance to the free return of blood from the spermatic vein.^ *********** Distention of the bowels by fasces or gas may produce ulceration. Several such ulcers, ulcers by distention, have been already reported.'^ In Case 4 reported in my ' Habershon, loc. cit., p. 318. ^ Henoch, Die Unterleibskrankh. ^ See Goodhart, loc. cit. 160 CONSTIPATION IN ADULTS paper, " On Treatment of Intestinal Obstruction by the Force Pump," ' it is stated: In some portions of the small intestine there loere noticed small holes, as if made by a punch; from the lack of any evidence of severe inflamma- tion in the surrounding structure, and from the general healthy appearance of the intestine, I loas led to the belief that these ivere post-mortem occurrences; if not, they might have appeared in the last thirty-six hours, ivhen the vitality was already very loio. These small holes were seen on the inner surface of the intestine and did not perforate it. They were about the size of the head of a ten-penny nail. I could not account for them at the time, but in the light of subsequent study it is clear to me that they were ulcers by distention, the intestines having been very much distended by flatus. *********** Accumulations of fseces and subsequent dilatation may not be unimportant factors in the production of enteropto- sis and dislocation. Habershon^ reports a number of cases of dislocation of largely dilated caecum. IX. Diverticula. — A further effect of the atony of the intestine and consequent prolonged detention of faecal matter therein is the formation of diverticula, that is, the sacculi or haustra, formed by the circular and longitudinal bands of muscular fibres, become distended. The faeces contained in them is removed from the onward current in the lumen of the bowel — and is thus less accessible and more difficult of expulsion — and this difficulty is rendered greater by the atony of the muscle. Further accumula- 1 American Journal of the Medical Sciences, January, 1886. ^ Loc. cit. THE CONSEQUENCES OF CONSTIPATION 161 tion still further distends the sacculus, and the pressure exerted may be so great as to effect a separation of the bundles of muscular fibre and a pushing out between them of the mucous membrane — constituting a hernia. False diverticula of the intestine. Dr. Bristowe.^ Case 32. In the second case (which was that of a woman cet. sixty-nine, who died of cancer of the stomach, liver, perito- neum, and pleura) were found throughout the whole length of the colon, but chiefly in the sigmoid flexure, large numbers of globular sacculi from the size of a pin's head to that of a marble. They all occurred in those portions of the intestine to which appendices epiploicse were attached, and projected into them. Their parietes were formed by a prolongation of the mucous membrane and by the fat of the appendices. The muscular coat was for the most part deficient, so that, though a few fibres were detected by the microscope in the walls of some of the smaller ones, the sacculi may fairly be looked upon as hernia of the mucous membrane. Their orifice of communi- cation with the intestine was comparatively small, circular, and smooth, and each one of them was filled by an indurated lump of fgeces, which allowed of ready enucleation. No stricture was detected, nor any other disease whatever of the large intes- tine. Its walls were totally free from cancerous growths, and no disease existed in the pelvis capable of producing obstruc- tion. It seems most probable, however, that the cause produc- ing this abnormal condition must have resembled that operating in the case of sacculated bladder ; very likely habitual costive- ness may have brought about some of the ill effects which might be expected to follow on actual obstruction. Wallman'^ saw in the case of an invalid who had reached the age of sixty-six years, nine true diverticula on the large bowel. 1 Transactions Pathological Society, London, Vol. VI. 2 Virchow's Archiv, Vol. XIV., p. 202. 162 CONSTIPATION IN ADULTS They were arranged as follows: One on the colon ascendens, three on the transverse colon, three on the colon descendens, and two on the sigmoid flexure. Of these, seven were on the free surface of the haustra. W. Hale White ' presented to the Pathological Society a specimen showing diverticula from one-third to one- half an inch deep on the descending colon, sigmoid flexure, and first part of the rectum. Each diverticulum had a fold of mucous membrane around its orifice. Case 33. J . V. Lentaigne. (Transactions of the Academy of Medicine in Ireland, 1884.) *********** On opening the abdominal cavity the large intestine was seen to be fringed by a double line of bluish-black, glistening tumors, mostly about the size of grapes, but some of them as small as swan shot, while a few were nearly as large as a pigeon's egg. On handling these they seemed to be quite solid and rather hard ; some of them hung from the gut by a short but narrow pedicle, whilst others were apparently sessile. . . . On opening the gut the central cavity was found to be nar- rowed and to contain but little fseces ; the muscular fibres, especially the longitudinal set, were very much hypertrophied. The mucous membrane presented a number of shallow depres- sions, each of which corresponded with one of the tumors on the outside. All the tumors were found to be pouches, each one tensely filled by a single lump of feeces of stony hardness ; they were lined by mucous membrane of a brownish color, but otherwise apparently normal, and the depressions seen on the inside of the gut were formed by a number of folds radiating from the tightly closed mouth of each cavity. These pouches were divisible into two classes, the greater number of them consisting simply of the normal pouches of tlie intestine, with more or less narrowing of the neck of the pouch ; 1 Transactions Pathological Society, London, Vol. XXXVI. THE CONSEQUENCES OF CONSTIPATION 163 the walls of the cavities were composed of the normal con- stituents of the intestinal wall, and their contents could be easily squeezed out into the general cavity of the intestine. The other set of pouches could not be emptied into the gut by squeezing, but were easily burst by much pressure ; their walls were very thin, and seemed to consist of mucous membrane and peritoneum only. Although no direct cases have as yet been reported, it is not difficult to under- stand how a per- foration of the intestine might very readily occur through the mucous mem- brane in one of the diverticula. The force required would not be very great, not near that, of course, required to rupture the three coats. In this way the cases of spontaneous rup- ture of the intestine are readily explained, and the results of necropsies seem to clearly point thereto ^ false diverticula. (From Treves' lutest. Obstruction .) 1 Herschl, Wiener medizinische Wochenschrift, 1880. No. 1, " Zur Mechanik , 1 Manipulation, Group E, 2 Manipulation, Group E, 1 Case 2. Considerable relaxation of the abdominal walls. First Week. Introductory Second Week. Effleurage. Manipulation, Group A, 1 Manipulation, Group A, 3, a Manipulation, Group J., 3, a, c Manipulation, Group A, 4 Manipulation, Group A, 4 Manipulation, Group C, 1, b Manipulation, Group (7, 1, b Manipulation, Group (7, 3, a, 6, c Manipulation, Group (7, 2, a Manipulation, Group 2 Manipulation, Group (7, 3 Manipulation, Group Z>, 1 Manipulation, Group (7, 4 Manipulation, Group E, 1 Manipulation, Group E, 2 Case 3. Pendulous belly. First Week. Introductory Second Week. Effleurage. Manipulation, Group A, 3, c Manipulation, Group A, 1 Manipulation, Group A, 4 Manipulation, Group A, 3, a Manipulation, Groiip A, 1 Manipulation, Group A, 2 Manipulation, Group (7, 1, b Manipulation, Group (7, 1, b Manipulation, Group (7, 3, a, b, c Manipulation, Group C, 2 Manipulation, Group B, 2 Manipulation, Group C, 3, a, b, c Manipulation, Group D, 1 Manipulation, Group O, 4 Manipulation, Group E, 1 Manipulation, Group E, I TREATMENT OF CONSTIPATION DUE TO ATONY 239 These schedules are used alternately, one week the one and the following week the other, and thus on throughout the whole period of treatment. It is of course understood that the requisite changes are made in the programme whenever the necessity therefor arises ; e.g. we will omit the more powerful manipulations, when from indiscre- tions on the part of the patient colicky or spasmodic conditions accidentally supervene, and confine ourselves to the mild and soothing eifieurage movements. Frequency of Treatment. — The patient should have no less than three treatments per week, — every other day is better, — and this with the greatest regularity. Usually in a very short time after the inauguration of the massage treatment, sometimes after two or three sittings, and in rare instances already after the first, the bowels will begin to move regularly every day, and patients may feel inclined to lessen the number of sit- tings per week. Still, as the stools are as yet hard and scibalous and insufficient in quantity, and as relapse readily occurs, the physician should insist most strenu- ously upon three sittings per week as an absolute neces- sity. Only when the stools have again resumed their normal form and are of sufficient quantity can the num- ber of sittings per week be lessened. One treatment per week or an occasional treatment cannot give any satisfaction, either to physician or patient. Duration of Treatment. — Under very favorable condi- tions six weeks may suffice, and the bowels, then function- ing normally, will continue to gain in strength and vigor from their own physiological action. Under other con- ditions three months may be required, and this is about 240 CONSTIPATION IN ADULTS the average period. This is also the experience of Le Marinel.^ It may even take longer. The dictum of that eminent clinician Nothnagel is, "Continue until success is achieved, even if it takes months and months." ^ Mode of Cessation. — I believe, and I carry this doctrine into practice, that the cessation of massage should be gradual. The rationale thereof can be readily under- stood ; we have so many analogous instances in medicine, and it was so essential a principle with the older physi- cian, that details as to the why and wherefore are not necessary here. When the patient has had three sittings per week, or every other day regularly for six weeks or any other period, and the bowels are acting regularly and normally, we reduce the number to two, then to one sit- ting, per week, and lastly to one in two weeks. We re- duce the number of manipulations, omitting gradually the more powerful ones. Then the patient can be dis- charged. In this way we fortify the good results already obtained, guard against relapses, and keep our patient under observation for a sufficient length of time to be fully assured as to the outcome of our treatment. ********** Instrumental Massage. — It has been suggested, and no doubt from pecuniary considerations and from reasons of delicacy, as where the operator is other than a physician, that mechanical appliances be used for the carrying out of massage treatment. Sahli ^ has suggested the use of a 1 Loc. cit. 2 Wiener medizinische Presse, loc cit. 8 " Ueber Massage des Unterleibs mittelst Eisenkugeln," Correspondem- Uatt Schioeizer Aerzte, XVII. 19, 1886. TREATMENT OF CONSTIPATION DUE TO ATONY 241 three- or five-pound old-fashioned cannon-ball covered with chamois-skin. This is to be rolled over the tract of the whole large bowel by the patient himself, either before rising in the morning or on retiring at night, or at both times. Dr. Ach. Rose has claimed some success with this method.^ Dr. S. Feilchenf eld ^ has employed steady pressure in the treatment of constipation, with meteorism and atony of the intestine. He has made for this purpose a cushion containing three to four pounds of shot, which by means of thin layers of cotton-wool are divided into equal and even layers, and the whole then thoroughly quilted through. The cushion is made in the form of the belly, so as to fit it, and to exert, when on, an equable pressure upon it. By means of bands or tapes it can be tied to the body, and thus kept in position. It can be applied in the morning before rising, or at night on retiring ; in a few cases he has allowed it to remain on all night ; usually, however, an application of one-half to one hour has sufi0.ced to call forth a regular stool. He has obtained good results with it also in haemor- rhoidal troubles. Dr. Arthur Kahn ^ has invented an apparatus for self- massage which is highly spoken of. This instrument is intended for the purposes of general massage, and not for that of the abdomen alone. As far as my own experience goes, I must say, referring 1 New Yorker medic. Monatschrift, January, 1893. 2 Deutsch. medic. Zeitung, No. 75, 1891. 8 Centralblatt f. Chirurg. u. Orthop. Mechanik, Berlin, 1889, V., p. 4, and personal communication. 242 CONSTIPATION IN ADULTS here to abdominal massage only, that the mechanical, appliances cannot replace the hand of the skilled operar tor, and especially if that operator be a physician. How- ever, this much must be admitted, that whenever patients cannot, for any reason whatsoever, avail themselves of the services of a masseur, instrumental massage is the Kahn's Roller. best and only substitute. Likewise when patients cannot have the treatment at the hands of a masseur with suf- ficient frequency, the use of appliances (and those de- scribed here I hold to be the best) in the interval will add materially to the efficacy of the infrequent manipu- lations of the physician. CHAPTER XVII TREATMENT OF CONSTIPATION DUE TO ATONY (Continued) Massage (continued); Swedish Movements. Kinesipathy (Heilgymnastik). — A branch of massage, and a not unim- portant one, is kinesipathy, or the Swedish movement cnre, so specially designated because it was in Sweden where the system received its greatest elaboration and found its most general application. It is maintained by some that kinesipathy is a necessary complement of massage, and must always follow it, and that massage alone is not very effective. Without at all disputing the value of these exercises, especially for those morbid conditions that pertain to the domain of ortho- paedics as has been set forth by Bush,^ I must say that so far as constipation is concerned I prefer that, when- ever possible, the patient shall take exercise in the man- ner described in Chapter XV., and I think it will be generally admitted that for this purpose such dietetic exercise is amply sufficient, really nothing else equal to it, and that kinesipathy, or medical gymnastics, can then be omitted from the list of measures to be employed- However, there are instances that come under observa- tion occasionally, where for one reason or another the patient cannot get the requisite dietetic exercise ; here 1 Handbuch der AUgemeinen Therapie, Ziemssen, Bd II, Th. II. 243 244 CONSTIPATION IN ADULTS the movement cure will find excellent application, and add to the efficiency of our massage treatment. As to the physiological action of these movements, the same principles pertain here that have been set forth in the section on exercise in general. The movements are divided into three great groups : 1. Active movements made by the patient himself without the assistance or interference of another person. 2. Movements against resistance. These movements always require an assistant. The resistance is offered now by the physician (or gymnast), now by the patient. 3. Passive movements, where the patient himself is altogether passive, the movements being made by a second person. It is generally desirable for the greater ease and com- fort of the patient, and the greater facility with which the movements can be made, that a special garb, such as is used in all gymnasiums for the purpose, shall be worn by the patient whilst taking these exercises. (The usual suit of woollen underwear as worn by most men in this country will do very well. For ladies, if they prefer, a loose, sleeveless vest of woollen or thinner material, a pair of drawers, and high stockings will fill all require- ments.) It is not, however, indispensable ; only, if the ordinary garb be worn, we must see to it that all bands (neck bands, belly bands, garters) be loosened, so that both respiration and circulation shall be perfectly free and unimpeded. As to the number of movements to be made at each sitting, that is a matter that must be decided for each case individually. The rule laid down for dietetic exer- TREATMENT OF CONSTIPATION DUE TO ATONY 245 cise, namely, that it should never reach the point of fatigue, holds good for medical gymnastics, and we will be governed therefore in our prescriptions by the habit and experience of the patient. We will, as a rule, begin with a smaller number and with weaker movements, and gradually, as the patient becomes accustomed to the exer- cise, increase the number of the movements or the fre- quency of repetition of each individual movement, as well as go over to such exercises as require greater force and greater exertion in their execution. Rules Begin with the weaker movements, put the more forci- ble in the middle, and close again with the weaker (about in the order of arrangement of the three groups here). The resistance movements should alternate with active movements of another part of the body. Thus after every such exercise the patient should take a turn for a minute or two the length of the room, or if the lower part of the body be engaged in the movements under resistance, he can make some of the active arm move- ments figured here. With the active and passive movements such pauses are not required. A gymnastic seance lasts from one-half to one hour. 1. Active Movements These movements are, as already stated, made by the patient himself by the voluntary exercise of his muscles without the aid or interference of another person, and constitute the essence of what is known as chamber gym- 246 CONSTIPATION IN ADULTS nasties. They can be made as well at the home of the patients, in the intervals of treatment (by the physician), as in a regularly arranged gymnasium. Patients must be carefully instructed not to contract the muscles spasmodically in the making of the move- ments. The movements should be vigorous and regular, and not entail any unnecessary fatigue. Fia. 1. Fig. 2. Fio. 3. Bending of the trunk forward and Lateral inclination of Rotation of the trunk, backward. Five to ten times. the trunk. Fivetoten Ten to fifteen times. times. Fig. 3. The patient, placing himself in the upright posi- tion, lower extremities firmly fixed, and with hands upon the thighs, rotates the trunk from right to left and left to right. Fig. 4. The person, placing himself as described above, rotates the trunk upon the hips from right to left and left to right, so that he shall describe a cone, the circular base of which shall be as extended as the lumbo-sacral articula- tion will permit. During all the phases of the movement TREATMENT OF CONSTIPATION DUE TO ATONY Fig. 4. Fig. 6. Fig. 6. Circular movement of the Extension and flexion of Extension and flexion trunk with inclination, to knee, forward. Five to of knee, backward, the right and to the left. ten times. Five to ten times. Three to six times. Fig. 7. Raising the knee as high as possi- ble, anteriorly. Ten to fifteen times. Fig. 8. Squatting and ris- ing. Three to six times. Fig. 9. Wood-chopping movement. six times. Two to 248 CONSTIPATION IN ADULTS the trunk is always face forward so that no twisting of the axis of the body is entailed. This movement is determined by all the muscles of the hip. By the observance of a certain cadence, all the muscles of the abdomen are alternately called into activity.^ Fig. 10. The patient places himself upon a couch in the Fig. 10. Rapid elevation of the upper and lower part of the body, alternately. Four to eight times. horizontal position, and, folding his arms upon his chest, raises his trunk and upper part of the body into the upright position without moving his lower extremities. It may be a little difficult to accomplish at the outset, and assistance may be required at first to hold down the legs, but this soon passes and the patient can execute the movement quickly and with ease. Then the body is thrown back upon the couch and the legs are drawn up, the knees flexed upon the thighs, and 1 Le Marine], loc. cit. TREATMENT OF CONSTIPATION DUE TO ATONY 249 the thighs upon the pelvis as far as they will go ; after holding them a few seconds in this position, they are extended vertically to their full height. Then these are lowered and the trunk raised, and so on, alternately. The movement of raising the trunk can be made still more difficult by placing the hands beneath the head, or by holding weights or dumb-bells in the hands and holding them near the body This movement brings into play all the abdominal muscles, and through them (besides by the direct pressure brought to bear) influences all the abdominal organs. It is, therefore, the most important of all the movements that are made. Fig. 10. Assistant holding down the legs. II. Movements against Resistance These movements always require the assistance of a second person, a gymnast or a physician. The resistance, made in the course of these movements, is offered, now by the patient, now by the physician. Although a certain amount of force must always be used in the course of these exercises, it must never be so great that the resist- ance cannot be readily overcome, especially by the patient, so that he shall not be compelled to excessive contraction ^ Le Marinel, loc. cit. 250 CONSTIPATION IN ADULTS of his muscles by which they will be thrown into a tremor, or that the physician shall be forced to unnecessary and useless exertion. All trials of strength are prohibited in medical gymnastics ; they prevent that equable and nor- mal contraction of muscle which it is the object of these exercises to effect.' Fig. 1 1 . The patient stan ds with his legs spread apart and raises his arms over his head, so that the volar surfaces of the hands front each other. The physician places himself before the patient, grasps both his arms about the elbows, and bends the trunk, the patient resisting, at first to the right. Then the patient raises his body against the resistance of the physician. Then the movement is made to the left, and so on, al- ternately, three to five times for each side. Women can sit whilst making this movement. Fig. 12. The patient Fig. 11. Standing spread. Alternating lateral inclinations. Fig. 12. Opposite-sitting. Trunk rotation. Reibmayer, Die Unterleibs-Massage. TREATMENT OF CONSTIPATION DUE TO ATONY 251 sits upon a chair or ottoman or stool, with knees brought together and the arms akimbo, with the hands resting upon the hips. The physician sits opposite, facing the patient; places his hands upon the latter's shoulders, and rotates the trunk, the patient resisting, to the right. Then the patient brings it back against the resistance of the physi- cian to the initial position. The movement is then made to the left. Three times to each side. Fig. 13. The patient places himself in a riding posture upon a high bench, and lays his head upon the left arm of the physician, who is behind him. The physician passes his left arm underneath the left arm of the patient, from before backward, al- lowing his hand to rest upon the patient's back. The right hand is pushed through from underneath the patient's right axilla, curves upward and forward so that the fingers come to lie upon the patient's shoulder. The physician now rotates the trunk toward the left, the patient resisting. The patient then brings his body back to the initial position, the physician ofPering the resistance. In making the rotations to the right, the physician changes the position of his hands, the right assuming that of the left, and the left that of the right. Fig. 13. Riding position. Trunk rotation. 252 CONSTIPATION IN ADULTS Fig. 14. The patient sits with closed knees upon a chair or stool with the hands resting upon the hips. The physician sits opposite, fac- ing his patient, places his hands upon the latter's shoulders, and bends the body forward, the patient resisting. The patient then straightens up again, the physician offering the resist- ance. Fig. 15. The male pa- tient is placed upon the high bench in riding posture. The physician stands behind him, places his hands upon his shoulders, and bends the body far forward, so that the whole abdomen is very well compressed, the patient mak- ing; resistance. The patient then brings his body back to the initial position, the phy- sician now resist- FiG. 14. Opposite-sitting. Trunk inclination. mg. Fig. 16. The patient is placed in the position for abdominal massage, with the flexed Fig. 15. Riding posture. Trunk inclination. TREATMENT OF CONSTIPATION DUE TO ATONY 253 knees in close apposition. The physician sits to the left of his patient, places his left hand upon the outer side of the patient's right knee, and the right hand upon the outer side of his or her left knee. The patient now spreads his knees apart, the physician resisting ; the left knee, in moving, comes in contact with the physician's left arm, and the right knee with the physi- cian's right arm. This makes the movements more equable Fig. 16. Half-lying. Knee separation, with lifting of sacrum. and less exhausting for the physician. Then the knees are brought together by the physician, the patient resisting. Fig. 17. The patient in the same position as for the previous exercise. The physician, to the left of the patient, places his hands on the inner sides of the latter's knees. He now spreads the knees apart against the resistance of the patient, and the patient brings the knees together against the resistance of the physician. In /ma/es, with each of the two movements just described 254 CONSTIPATION IN ADULTS the patient raises her pelvis till it is almost on the same plane with the head and the knees. In males the elevation of the pelvis is unnecessary (ex- cept if atony and prolapse of the rectum be present, then the exercise is made just as in females). The resistance then not being as great, the phy- sician can place himself more Fig. 17. to the feet of Half-lying. Knee closure, with lifting of sacrum. , , , . the patient, facing him, as shown in cut. (a) Knee closure. (6) Knee separation. TREATMENT OF CONSTIPATION DUE TO ATONY 255 Fig. 18. The patient squats down and holds himself in this position by resting his hands upon the pins of a mast (as in the cut) or upon the back of a chair. The physician, to the right of the patient, places his right hand upon the pa- tient's abdomen and his left upon the back, about the lumbo-sacral junction. The patient, holding his knees firmly together, now raises himself to the full upright position against the resistance of the physician. In raising himself, the patient describes an arc-line, upward and for- ward, with his pelvis. Fig. 19. The patient lies down upon a table, belly down- ward, but so that only the lower extremities rest upon the table, whilst the rest of the body is free therefrom and entirely unsupported. The feet must be held down upon the table by an assistant, whilst the patient must hold his body out in the horizontal position. As this movement entails a high degree of tension upon the abdominal muscles, the patient must be assisted at the outset in getting into position. It is done in this wise : The patient kneels upon the table, and after the feet have been fixed down by an assistant, the physician catches the patient with his arms under both axilloB and brings him into the desired posture. He then lets go, allows the Fig. 18. Squatting with arc-like rising. 256 CONSTIPATION IN ADULTS patient to retain this horizontal position for a few seconds, and again placing his hands upon the patient, about the region of the false ribs, brings him back to the kneeling position upon the table. This exercise has an invigorating and strengthening effect upon the muscles of the belly, the back, and the loins. III. Passive Movements Movements in which the patient is altogether inactive. Fig. 20. The patient places himself in the semi-recum- bent position. The physician, standing by the side of the patient, lays one hand upon the patient's knee, and with the other he grasps the foot about the metatarsal bones or about the ankle joint, and now makes rapid flexion and exten- sion in the hip joint. This alternate flexion and extension of the hip joint is repeated six or eight times for each leg. The knee must not be flexed too strongly in making the movement. Fig. 21. The patient kneels upon an ottoman or cushion. The physician, standing behind, places his hands firmly be- neath the patient's axillae and rotates the trunk with a rather rapid motion (no resistance must be offered by the patient) ten to twelve times. A short pause can be made in the middle of the exercise. Fig. 22. The patient sits upon a high bench or upon a narrow stool, with his arms akimbo and with the hands upon his hips. The physician or gymnast places himself behind the patient, lays his two hands upon the latter's shoul- ders, and rolls his trunk, the patient making no resistance at all, three times to the right and thrice to the left. As TREATMENT OF CONSTIPATION DUE TO ATONY 257 258 CONSTIPATION IN ADULTS the physician or gymnast only controls the movements, it devolves upon the patient to maintain his equilibrium, that is, to call gradually into activity all the muscles that balance the trunk. During the movement, the head and upper part of the body are to be held as straight as pos- sible. The movements must not be jerky, and the shoul- ders must always be turned on the same plane. Fig. 22. Trunk-rolling. Riding position. Fig. 23. Hip rotation. Standing posi- tion, with arms elevated. Fig. 23. Patient stands with the legs well together, ele- vates the arms fully above the head, and, separating them widely, grasps a pole (which hangs down from above, or which is merely placed in his hands). The physician, be- hind, places his hands upon the patient's hips, and whilst the latter, with feet firmly planted, seeks to maintain the upright position, the physician rotates the pelvis rapidly TREATMENT OF CONSTIPATION DUE TO ATONY 259 around in a circle to the right three to six times and as many times to the left. The patient's pelvic and hip mus- cles must be as passive as possible during the movement. In cases of flabby abdominal walls, or even pendulous belly, so often met with in married women, and in the large, full, rounded abdomens indicative of an abundant panniculus adi- posus, the movements shown in Fig. 10 of Group I., and that shown in Fig. 20 of Group II., are especially indicated and of the greatest service. Machine Movement Cure ; Machine Gymnastics (Maschinelle Heilgymnastik) I. Dr. G. Zander, of Stockholm/ invented and per- fected a series of machines by which the resistance movements and the passive exercises can be made with but little loss of time. In many of the large cities of Europe, and in one or two in America, special institu- tions have been established, fitted out with the machines, and operated for the sole purpose of thus treating patients. If such an institution is at hand, the physi- cian, if he so desires, can avail himself thereof, and recommend his patient thereto, for the gymnastic part of the treatment. It must be stated, however, that, in the opinion of experts in this matter, the machine method has no other advantage over the manual than that of greater facility and greater rapidity in the handling of patients.^ II. When such an institution is not convenient, and when, for any reason whatever, the physician himself cannot give the patient the benefit of the second and 1 Bush, Reibmayer, loc. cit. ^ Reibmayer, loc. cit. 260 CONSTIPATION IN ADULTS third group of gymnastic exercises, he can avail himself of certain other mechanical devices for resistance exer- cises which the patient can readily use at his own home. Such machines are: the rowing apparatus of Sachs (Fig. 24), the rowing apparatus of Ewer (Fig. 25), and the restaurateur of Sachs (Fig. 26).^ For greater safety, a thick cord of a certain length is run through the rubber tubing of the different Sachs machines, so that in case of a break or tear, the patient will not fall back and do himself injury. *********** Contra-indications to Massage When not to practise it. — In all cases where, upon examina- tion, the bowels are found to contain very much indurated faeces, masses of stone-like hardness that cannot be readily broken down with the fingers, massage treatment will not be instituted until the intestinal canal has been thoroughly cleared by means of injections of water, of oil, by means of oil adminis- tered freely by mouth, and reinforced by clysters, by means of the scoop, or even of the hand.^ Otherwise there is danger of lacerating, or even of perforating, the intestine in the course of the manipulations. During the menstrual period, the treatment should be inter- mitted. It should not be resumed till a few days after the cessation of the flow. In chronic diseases of the female genital tract, as pelvic cellulitis, retro- or peri-uterine haematocele, chronic inflammation of the ovary, of the tube, we must refrain from the more forcible, from the more powerful, manip- ulations, already described. We will confine ourselves 1 Reibmayer, loc. cit. ^ See History, p. 148. TREATMENT OF CONSTIPATION DUE TO ATONY 261 1 Fig, 24. Fig. 25, a, middle section of the boat ; I, seat run- ning on a rail ; k, movable footboard ; h, rud- der that can be carried in any direction by reason of c, d, i, ball and socket joints ; b, ar- rangement to hold the rudder firmly. In the brass tube /, a piston-rod is worked up and down by the rudder, and to effect its easier return a spiral spring is arranged in the tube g. To make the work accord with the strength of the worker, the following further arrange- ments have been provided thereon : The centre of motion of the rudder is movable ; the nearer it approaches to c, the more easily the move- ments are made. In the tube /, at the point i, there is a slit which can be entirely closed or kept more or less open by a ring. The larger the opening, the more freely the air can rush in under the piston, and the easier the work will be. Fig. 26. a, Movement with Sachs Restaurateur. b, Goodyear's Pocket Gymnasium. 262 CONSTIPATION IN ADULTS here to the mild effleurage and very gentle and rather superficially made frictions ; ^ still, so, that whilst having due regard for the pathological conditions present, we shall obtain regular action on the part of the bowels, which in itself will have a reflex curative effect. Case with greatly enlarged Spleen. A. Outline of Spleen. B. Line of Massage for Sigmoid Flexure and beginning of Rectum. For the novice in massage manipulations, pregnancy should constitute an absolute prohibition therefor. Massage (gymnastics always, of course, included) is to be rejected in all acute inflammations of the intestine, of the peritoneum, or of the intra-abdominal vessels ; in all forms of ulceration (round or tubercular) of the stomach or of the bowels ; in all cases of tumor (polypus, ^ See Manipulations, in the section devoted to the Massage of Children. TREATMENT OF CONSTIPATION DUE TO ATONY 263 sarconica, carcinoma, etc.) within or around the alimentary tract.^ In a case of greatly enlarged spleen overlying the whole left half of the transverse colon, the left colic flexure, and the larger part of the descending colon, I directed the massage from the caecum upwards over the transverse colon as far as the right border of the enlarged spleen, making the various manoeuvres already described; then the hand was carried over into the left iliac region at the lower border of the spleen, and the sigmoid flexure and the beginning of the rectum were manipulated. The spleen itself and the parts beneath were left untouched. The result of treatment was all that could be desired. On Massage and Swedish Movement Cure (Gr^mnastics') Reibmayer. Die Technik der Massage. Die Unterleibs-Mas- sage. ScHREiBER. Praktische Anleitung zur Behandlung durch Massage und methodische Muskeluebung. Berne, G. Le Massage. Paris, 1894. OsTROM, KuRRE W. Massage and the Original Swedish Movement Cure. Philadelphia, 1890. ScHREBER. Aerztliche Zimmergymnastik. Leipzig, 1884 (19th Edition). Fromm. Zimmergymnastik. Berlin, 1887. 1 Reibmayer, Die Unterleibs-Massage. Le Marinel, loc. cit. CHAPTER XVIII TREATMENT OF CONSTIPATION DUE TO ATONY (Continued) Hydrotherapy The measures to be considered here, having especial reference to their applicability in the treatment of consti- pation due to atony, are : Clysters. Cold tub-baths. Douches (showers). Cold compresses. Cold moist-frictions. 1. Clysters. — Rectal injections, medicated and other- wise, are well known, as also their mode of administra- tion. The fountain syringe, with a bag of the capacity of two or three quarts, is generally the most useful and the most convenient instrument, as it does not require the intervention of a second person as is the case with the various other kinds of syringes. There is one defect, however, that is common to them all, namely, that the rectal point is too short. The effect of this is that it permits of the ampulla of the rectum becoming filled too quickly and overdistended, and thus a further and higher ingression of the fluid is prevented. Where this is of rather frequent occurrence, a marked dilatation of the pouch with atony of the rectum will 264 TREATMENT OF CONSTIPATION DUE TO ATONY 265 result. A longer nozzle, about the length of the vaginal point (about five and a half inches), is an absolute neces- sity, and where such cannot be had a rectal tube will obviate the difficulty. A very important point, one not to be forgotten in our instructions to the patient, is that of position. The per- son to take the injection should place himself in the hori- zontal position on the bed or couch, with a pillow beneath the hips so as to elevate the pelvis and give the lower half of the trunk a downward inclination, facilitating thereby the inflow of the water and increasing its force. I have always found this satisfac- tory, and have never been required Self-acting Cltsopump. to resort to the knee-elbow position sometimes recom- mended. The injection should never be taken in the sitting posture, as is so frequently done by women. For habitual constipation cold water injections have long been recommended, and I have myself in some few cases obtained very good results therewith. These injec- tions differ from the other and manifold clysters, in that they are not medicated, that the quantity of water in- jected is usually larger, and that the temperature of the same is considerably lower. 266 CONSTIPATION IN ADULTS The amount of water for an injection is from one-half to two quarts, which, with the apparatus named and the position described, will readily flow in. The temperature of the water should be from about 80° F. to 75° F., and as the patient becomes accustomed thereto it is gradually reduced still further to 70° F., and even to 65° F. It should not be lowered beyond this. When water of a lower temperature, 65° F. to 55° F., is used, not more than one-half or three-fourths of a pint should be injected, as otherwise dangerous fluxions or congestions of the inter- nal organs might result. At the outset of the treatment if the bowel, especially the lower part thereof, is filled with very hard fgeces, the water injected may have a higher temperature, 90° F. and even 95° F., as thereby the masses are more readily softened and their expulsion facilitated. Huhnerfauth^ proceeds in this wise: He first empties the lower bowel with a moderate quantity of water, at a temperature of from 77° F. to 69° F., or, at the outset of the treatment, if there be much hard faecal matter, at a higher temperature. Following this, a larger quantity of water, one-half to one litre,^ at a temperature of from 86° F. to 77° F., is allowed to flow in slowly, and the patient told and coaxed to retain it as long as possible. Gradually, as already stated, the temperature of the water for the injections is lowered. As to the frequency with which these injections are to be taken, that will depend upon whether the clysters con- 1 Dr. George Huhnerfauth, Ueber die habituelle Obstipation u. ihre Behandlung, etc., Wiesbaden, 1890. 2 A litre = 2.1135 pints (Dunglinson's Medical Dictionary). I TREATMENT OF CONSTIPATION DUE TO ATONY 267 stitute an essential element of the treatment, or whether they are only incidental thereto. (a) Where they constitute an essential feature, they can be taken at first every day, then every other day, and, as the peristalsis becomes more vigorous and more active, at longer intervals. They can be taken at almost any convenient hour. Force Pump. Before arising in the morning, two hours after breakfast, or just before retiring at night, are perhaps the most suitable periods. If possible, the injection should always be taken at the same period of the day, as some regularity is also here of apparent benefit. In cases of great obstinacy, where the lethargy of the bowel amounts almost to a paralysis, a more powerful 268 CONSTIPATION IN ADULTS and more effective instrument will be required. Here the force pump will render excellent service.^ If the cold injection does not prove satisfactory, we may avail ourselves of the powerfully stimulating action of rapid alternation of temperature by alternate hot and cold injections. A cold injection is taken, or given first and followed, fifteen minutes after its discharge, by a hot one, — temperature of the water 101° F. to 103° P. It is with clysters as with drugs ; persons soon become accustomed to them, and then they cease to be effective- This must be guarded against, and can be readily accom- plished by the variations in the temperature of the water, by variations in the quantity of the fluid injected, by having care not to distend too suddenly or to overdistend the ampulla of the rectum, — all in the manner already described. Moreover, we must warn against the abuse of the clyster. Taken every time the desire for stool arises, the necessity for the abdominal pressure, which, as has already been said, is so important an element in the act of defeca- tion, is done away with ; the abdominal muscles get out of the habit of acting in this way, and constipation results, or, if already present, is greatly aggravated.^ (6) Where clysters are only an incident in the treatment of constipation by massage or electricity. As we are fre- quently not able to obtain in the early period of treat- ment a sufficient discharge from the bowels by these measures, and as it is one of the chief rules of treatment 1 See ray paper on "Intestinal Obstruction," American Journal of the Medical Sciences, January, 1886. 2Winternitz, Hydrotherapie, Handbuch der Allgemeinen Therapie, Ziemssen. Beni-Barde, Nouveau Dictionnaire de Medecine. TREATMENT OF CONSTIPATION DUE TO ATONY 269 that the use of purgatives must cease at once, we will, when- ever the necessity for a more thorough clearing out of the intestinal canal arises, i.e. when the effects of the reten- tion become too disagreeable for the patient to endure any longer, avail ourselves of the clyster to afford the relief required. This may be once in three or four days, once a week, even once in two weeks. The ordinary cool injection, water at the temperature of from 80° F. to 75° F., will fully answer the purpose. As to the mode of action of the clyster upon the intestine, it may be said that it is 1. Mechanical. — The intestine is distended by the mass of water injected, and the muscles thereof are thus excited to contraction. 2. Thermal. — It has been demonstrated, both experimentally and clinically, that cold water will arouse the peristaltic move- ments of the intestines, and this so markedly that not infre- quently they can, in rather thin persons, be discerned through the abdominal parietes. Warm water allays peristalsis, and it is for this reason that constipation is so generally observed in persons addicted to warm injections.^ Hot water, like cold, excites peristalsis, as I have already set forth elsewhere. ^ Both these moments act upon the ultimate nerve filaments distributed in the mucous coat, and through them the various muscles are aroused to action. Moreover, by reason of the stimulation of the ultimate nerve filaments, of the direct mechanical influence of the impact of the water upon the tissues, and of the contraction of the muscles, the blood-vessels are contracted, the blood is driven forward more rapidly, the contracted vessels dilate, are again contracted, and thus finally the whole intestinal and gastric circulation is accelerated. A greater amount of oxygen is carried to the parts, the energy ^ Winternitz, loc. cit. ^American Journal of the Medical Sciences, January, 1886. 270 CONSTIPATION IN ADULTS oi the nerve action is heightened thereby, and, as a result, the physiological functions are much better performed. It acts upon the intestines in still another way. It has been shown by the investigations of Rohrigi that injections of water into the rectum increase the rapidity of the portal circulation and heighten the pressure in the hepatic cells. There is an increase in the quantity of bile secreted, and increase of bile means exaggeration of peristalsis. The methodical use of rectal injections of cool or cold water is more especially indicated in the cases of ha- bitual constipation dependent in a measure upon internal haemorrhoids. In the constipation of chronic intestinal catarrh. In the constipation connected with icterus. Intestinal irrigations, with one to two litres of water at a tempera- ture of 77° F. to 73° F., methodically carried out, one to three times a day, have, according to Krull, given most excellent results in jaundice. There is a rapid abatement of all the annoying symptoms.^ Small injections of very cold water, temperature 60° F. to 55° F., are very effective in the hyperaBsthesia of the rectum sometimes found associated with neurasthenia and hysteria. 2. The Cold Tub-Bath {Halbbad, Winternitz). — The cold tub-bath is the bath in the ordinary bath-tub, with the water at the temperature as it flows from the hydrant, plus what it may gain from standing in the tub over night. It is always my direction that the water be allowed 1 " Experimentelle Untersuchung iib. die Physiologie der Gallenabsonde- rung." Wiener mediz. Jahrhiicher, 1873. 2 Mosler-Krull, Berliner liin. Wochenschrift, 1877. TREATMENT OF CONSTIPATION DUE TO ATONY 271 to run into the tub the night before, and to stand therem till morning. In winter, the bath-room should be well heated, so that there may be no danger of taking cold on emerging from the bath. The cold bath should be taken daily ; the best time is on rising in the morning, or just before dinner (noon). I never advise it at night. Before getting into the tub, the hands and forearms, especially about the wrist, should be well moistened with cold water; then the face and neck, and then the head. The chest (thorax) should now be well wetted, and in warm weather, or with persons who perspire very freely, also the axillae. The bath proper, which in summer may be of longer duration, should not last over a minute in winter ; very obese persons may prolong it to three minutes. However, summer or winter, it should always end before the second chill can come on. Whilst in the bath, and just after getting out, vigorous friction with a very coarse towel, or with a bathing-glove, or with a flesh-brush, should be made. For persons not accustomed to cold bathing and rather afraid of it, I direct that they get into the bath with the water at 95° F., and that then, whilst they are in it, the temperature be gradually reduced, by the' addition of cold water, five degrees. After a few days, they will get into the bath with water at 92° F., and reduce it, whilst they are in, five degrees. By this method of gradual reduction of the initial temperature of the water, and a further reduction of five degrees, the system be- comes gradually, and still very quickly, inured and accus- tomed to cold water, so that in a short time the cold / 272 CONSTIPATION IN ADULTS bath Avith the water as it flows from the hydrant will become not alone a pleasure, but a daily necessity. When the indications, therefore, exist, the bath may be made more stimulating by the addition of salt, chloride of sodium (common or sea salt), to the water. (From five to nine pounds of salt to thirty gallons of water.) Its mode of action is this : The cold bath stimulates the whole nervous system and gives tone to it, acting as it does upon the ultimate nerve filaments throughout the cutaneous surface of the whole body, and perhaps, also, directly upon the cord. The process of combustion, i.e. oxygenation, is hastened and made more extensive ; respiratioa is deepened ; the circulation is invigorated, and all the other physiological functions are quickened and more perfectly performed. In this way the tone of the muscular system is raised, and the muscles aroused from their lethargic state. Furthermore, the cold water acts directly upon the muscles, causing them to contract, — clearly demonstrated by the cramp in the calves, or in the feet, that occasionally seizes the bather on getting into the cold water. The abdominal muscles are invigorated, and their lost tone is restored to them. By the increased combustion, excess of fat deposited around the intestines is consumed ; by the quickening of all the other functions and their more perfect performance, by the contraction of the muscles, any redundancy of tissue in the abdominal walls is taken up, reabsorbed. They lose their flabbiness, become firm, afford the requisite support to the abdominal organs, and are adequate to exercise, when called upon, that pressure upon the bowels which is so necessary to normal defecation. The cold bath is specially indicated in the constipation of neurasthenia. In conditions of great flabbiness of the abdominal walls, — pendulous belly. TREATMENT OF CONSTIPATION DUE TO ATONY 273 In the constipation due to large deposits of fat in the mesentery and around the intestines. The salt bath should be advised for persons who do not react quickly to the cold water alone. It is of ad- vantage in ansemics, in cases of chlorosis, and in jaundice. 3. The Cold Moist-Rubbing [Die Kalte Abreihung).— It is made in this wise: A large sheet (bed sheet) is folded up, placed in a bucket of cold water, and allowed to remain therein over night. (If it be dipped and wrung, out of cold water several times, shortly before using, it will answer very well.) In the morning it is wrung out, unfolded, and thrown from the back over the shoulders of the person to be treated, like a mantilla. The assist- ant (a member of the family, friend, or bath attendant) now places his hand upon the sheet, as it lies upon the body, and with long, up-and-down strokes rubs the dorsal, whilst the patient, grasping the various forward ends of the sheet, rubs the anterior surface of the body with them. Or it may be applied in this way : The assistant having wrung out the sheet holds up one corner, and, placing the further corner of the same side in the axilla of the patient, folds the sheet around him completely, and as smoothly as possible, from the neck down, by the corner which he holds. The free end coming over the still bare shoulder (in the axilla beneath which the further end of the sheet is held) is stuffed into the ring formed at the neck. The anterior borders are folded around the lower extremities and held there by them, they being brought together. Placing his hand upon the sheet, he now rubs the body with it in long up-and-down strokes, as already stated. 27-4 CONSTIPATION IN ADULTS Care must be had that all the various parts of the body are well rubbed, and« several times each. Application of the Wet Shekt. {Preller.) The moist friction is made from three to five minutes (at the outset of the treatment the shorter period will sufiice), then the wet sheet is let fall, and a dry one, ready TREATMENT OF CONSTIPATION DUE TO ATONY 275 at hand, wrapped about the patient, and his body well dried. Just as for the cold bath, it is necessary that the patient shall well moisten his hands, forearms, face, head, and neck with cold water before the wet sheet is thrown over him^ to guard against a possible internal fluxion that might result from the sudden contraction of the cutaneous capillaries. On rising in the morning or shortly before dinner (noon) are very suitable periods for this treatment. As to its mode of action, all that has been said of the cold bath will apply here. The process of combustion is accelerated, the respiration is deepened, and a greater quantity of oxygen thus carried into the body. The tonus of the vessels is elevated, and the circulation is invigorated. The ultimate nerve fila- ments are powerfully stimulated, and this stimulation is trans- mitted to the cord and cerebral centres, and as a consequence the nervous or mental equilibrium, which may have been dis- turbed or depressed, is restored to the normal. The result of all this is that the various functions are better performed, and greater energy imparted to the muscular system. In all cases where the cold tub-bath is indicated but cannot be had either for lack of facilities or by reason of disinclination of the patient, the cold moist-rubbing will prove an excellent and effective substitute. It is of great benefit in neurasthenia, in the constipa- tion due in a great measure to hsemorrhoids, and in that condition described as irritable rectum. 4. The Cold Abdominal Compress {Neptune's Girdle). — Of strong towelling, forty to fifty centimetres (sixteen to ^ As to the further reasons for this, consult Winternitz, Hydrotherapie, and Beni-Barde ; see especially the experiments of Brown-Sequard, Edwards, and Tholozan. 276 CONSTIPATION IN ADULTS twenty inches) in width (dependent upon the girth of the person, the longer the girth the greater the width required), sufficient to encircle the lower half of the trunk three times, is taken, and two-thirds of this placed m very cold water, and allowed to remain therein for some time (about an hour). It is then wrung out, rolled up into the form of a roller-bandage beginning with the dry end, and then swathed around the lower half of the trunk. In this way the moist portion of the bandage will come upon the body, and will be covered by the dry part thereof. The whole is kept in place by long tapes attached to the extremity of the bandage. The whole bandage can be covered with a covering of flannel, or if evaporation is to be entirely prevented, a piece of oiled silk or gutta-percha paper can be laid over it. The best time for the application of this wet compress is the night. I direct the patient to put it on before retiring at night, and to take it off in the morning before he gets out of bed, and to dry immediately and thoroughly the part where it had been applied. Hiihnerfauth ^ advises that in the winter season patients applying the wet girdle at night should wear a flannel bandage around the abdomen during the day. The mode of action is the same, though of course limited in extent, as that of the other procedures already described. The application of the cold bandage has a strong, stimulating effect upon the nerve endings and the vessels, particularly in that part of the body which is always kept warm. The cutaneous capil- laries and blood-vessels are contracted, and the blood driven in upon the abdominal organs. A reaction, however, soon follows. 1 Loc. cit. TREATMENT OF CONSTIPATION DUE TO ATONY 277 The bandage is soon warmed, and by reason of bad conduction becomes blood-warm. The water therein is converted into vapor, forming a layer between the skin and the bandage ; this stimulates the dilation of the cutaneous blood-vessels, and draws as it were the blood from the abdominal organs outward into them. In this way, the internal organs are unloaded, and any tendency to hypereemia or congestion relieved. Besides this local action it has a more general effect. The stimulation of the nerve endings is transmitted to the cord and cerebral centres, and the various organs are more vigorously innervated and stimulated to a better performance of physio- logical function. This effect will be in proportion to the degree of coldness of the bandage when applied, and to the length of time it remains moist. Where, as occasionally happens, the bandage does not warm sufficiently; where it causes a contraction of the blood-vessels only, and the reaction does not follow; where, consequently, the skin beneath remains pale and ansemic, — it indicates that the stimulus of the cold in the bandage was not sufficiently strong. We can remedy this, and avoid the unpleasant effects that might follow, by preceding the application of the girdle with more vigorous thermic and mechanical influences. Before the bandage is put on, that part of the body should be rubbed well with very cold water. The required reaction will then very soon follow the application of the wet abdominal bandage. ^ It is indicated in the constipation of chronic gastric or intestinal catarrh ; in that dependent upon defective func- tioning of the intestinal secreting apparatus ; in the con- stipation connected with hepatic disturbances; in feecal retention due to irritability or hypersemia of the various female genital organs. 5. The Douche {Shower Bath, Fall-hdcler). — This has ^ Winternitz, Handbuch der allgemeinen Therapie, loc. cit. 278 CONSTIPATION IN ADULTS numerous forms : The rain bath (shower bath), the circu- lar needle bath, the mobile fan douche, etc. The water used in the douche may be either cold alone or hot and cold alternately, and then it is called the Scotch douche. Where a properly arranged bathing or hydriatic insti- tute is at hand, and the patient is in a position to avail himself of its benefits, we can advise that he take alter- nately the circular needle bath and the cold rain bath for from one to one and one-half, or even to two minutes (as he gets accustomed thereto), and that this be followed by the application of the fan douche (Scotch, where it can be had) over the region of the large bowel, and more particu- larly over the region of the caecum and sigmoid flexure. In ansemics, rather feeble persons, and such as do not react well to cold, the douche should be preceded by a warming-up procedure, such as the hot-air bath of a few minutes' duration. This will effect an accumulation of sufficient warmth to enable the system to better resist the depressing action of the cold, and the already stimu- lated nervous system will tend to a quick and healthful reaction.^ Where for any reason the advantages of such an estab- lishment cannot be had, I advise my patients to arrange an abdominal douche for themselves, in this way : A piece of rubber tubing twenty to twenty-five inches in length is attached to the faucet of the hydrant, preferably in the bath-room if there be one, and the patient having placed himself upright either in the bath-tub or in an ordinary wash-tub, at a distance from the mouth of the tube, the 1 Winternitz, loc. cit. TREATMENT OF CONSTIPATION DUE TO ATONY 279 stream is turned on and directed (a second person holding the tube) against the patient's abdomen. When it can be had, I have a nozzle having several small openings, some- thing like this. or round like that of a sprinkler, attached to the tube. Any tinsmith can furnish such a nozzle. Where the house is provided with a hot-water arrange- ment, we can, by attaching a like piece of tubing to the hot-water faucet, have a Scotch douche for our patient. Where for any reason this simple arrangement cannot be made, for want of proper facilities or what not, I have insisted upon my patient buying or borrowing a bath-tub, and having obtained it to take a douche in this wise : The patient lies down in the tub, and a second person (an assistant, friend, or member of the family) having filled a large pitcher with cold water allows it to flow in a small stream from a height of five or six feet upon the patient's belly, following the position of the gut. He can be douched in this way with hot and cold water alternately. Sprinklers- 280 CONSTIPATION IN ADULTS I have obtained very good results with this rather crude arrangement. I have usually found the morning hour, on rising from bed, when the body still retains the warmth accumulated therein, as the best time for the procedure when carried out at home. The douche is undoubtedly the most powerful of all the hydropathic measures, and great benefit will be derived from it, especially when employed in combination with other measures. As to its mode of action, it may be said that the douche pro- duces its effects by its mechanical action and its thermic influ- ences, and that both can be magnified or depressed according to the mode of production of the douche. Otherwise it acts like the other procedures of this method already described, only in a greater measure by reason of the plus influence of the impact or concussion. There is a general stimulation and elevation of energy of the whole cerebrospinal nervous system ; the circulatory and res- piratory apparatus are invigorated, and the muscular system acquires greater force. Thus Maggiora and Vinay ^ have shown that a rain bath of 50° F. under a pressure of two atmospheres increases the work-capacity of the muscular system threefold; the Scotch douche, ranging from 98° F. to 53° F., doubles the muscular force ; even douches of tepid water produce consider- able effect. Applied to the abdomen, it acts more directly upon the parts concerned and soon provokes energetic and persistent peristalsis. It is indicated in all forms of constipation, but espe- cially so in the cases of dilatation of the gut or any section thereof, a consequence of the constipation and tending to perpetuate it. 1 Blatter/, klinische Hydrotherapie, January, 1892. TREATMENT OF- CONSTIPATION DUE TO ATONY 281 In cases of constipation with marked atony or ectasia of the stomach. If hydropathy be the method selected wherewith to treat our case of constipation, of the measures described one will be ordered in all cases, namely, clysters, and cir- cumstances and conditions already detailed will govern us in the selection of the others. Thus in a case where deposit of fat appears to be the real etiological factor, we will also prescribe the cold bath ; if this cannot be had, the cold wet-rubbing. In addition we will direct that twice or thrice weekly an abdominal douche be taken — Scotch douche by preference. Where an atony of the gut is the cause of the constipa- tion, or where marked dilatation has already ensued, we will employ by preference, in combination with the clyster, the douche. In depressed conditions, as in hypochondria or mild types of melancholia, the douche, preceded by the hot-air hath, will be the treatment ; or if not this (as when the appliances are not at hand, or the patient cannot avail himself of an institute, or if the heat, the force, are contra- indicated), the cold moist rubbing. If an intestinal catarrh be the foundation of the de- rangement, we will resort, in addition to the clysters, to the cold compress, Neptune's girdle, and to an occasional douche. And so on, as already set forth above. *********** For a clearer understanding as to the exact meaning of very cold, cold, hot, the following table of Dr. Beni-Barde is here given. 282 CONSTIPATION IN ADULTS 46° F. to 53° F. 53° F. to 61° F. 61° F. to 68° F. 68° F. to 78° F. 78° F. to 86° F. 86° F. to 104° F. Above 104 . . Very cold Cold Fresh Chill taken off Tempered or lukewarm Warm Hot^ Winternitz, "Hydrotherapie," in Ziemssen's Handbuch der AUgemeinen Therapie, Vol. II., Part III. Winternitz, Die Hydrotherapie auf physio- logischer Grundlage, 2 vols. Beni-Barde, Manuel Medical de Hydrotherapie. Brouardel, P., L'Eau et les Maladies, 1892. Kriiche, A., Lehrbuch der prak- tischen Wasserheilkunde. Lange, Wasserkuren im Eigenen Hause. Duval, Traite Clinique et Pratique d'Hydrotherapie, Paris, 1888. Baruch, " The Uses of Water, etc." Preller, Anleitung zum Gebrauch der Wasserkur u. der Kiefernadelbader, Ilmenau, 1884. 1 Nouveau Dictionnaire de Medecine, Jaccoud. CHAPTER XIX TREATMENT OF CONSTIPATION DUE TO ATONY (Continued) Electricity That with the electrical current we can, under ordinary conditions, provoke an evacuation of the bowels is a fact well attested by numerous observations. This point is indeed so well established that Curci ^ claims that by means of electricity we can readily make the differential diagnosis between obstipation due to atony and impaction of fseces, and occlusion of the bowel by intussusception volvulus, internal strangulation, etc., in those obscure cases where by reason of absence of characteristic symp- toms the exact condition confronting us cannot be other- wise made out. Whether it will suffice as a method of treatment for the permanent relief of atonic constipation, that is still a question upon which opinions differ. Erb,^ from personal observation, confirms the very favorable reports of Benedikt," Scapari,* Stein,^ and ^ " L' elettricita contro la paralisi e la paresi intestinale," Jl Raccoglit. Med., 1877, 30. 2 Handbuch der Electrotherapie (3 Bd. der Allgm. Therap. Ziemssen). « " Ueber d. Electr. Behandlung der Obstipation," Allg. Wien. Med. Zeitung, 1870, 33. ^"L' elettricita nella coprostasi da atonia intest.," Ann. unives., 1881, Febbr., p. 97. * " Die farad. Behandlung der Obstipation," etc., Centralblatt f. Nerven- heilkunde, 1882, No. 9. 283 284 CONSTIPATION IN ADULTS Others, and recommends it as a most excellent measure for the relief of the derangement. Rockwell^ holds a like opinion. Leubusher,=^ in a study of the question, reported fifteen cases observed by him in the Institute for Nervous and Mental Affections, of Professor Binswanger. Oat of these fifteen cases, there were but four in whom the result was at all permanent; that is, that the bowels still acted regularly three months after the cessation of the treatment. In two cases no result at all was ob- tained, and in the others the relief afforded was but temporary, the patients relapsing into their former con- stipated state upon the cessation of the electrization. That occasionally, even frequently, it fails altogether, is admitted by Erb, Rockwell, and others. That it is a most valuable aid to other measures, of this there can be no doubt. NothnageP recommends it combined with massage ; Hiihnerf auth * employs it in com- bination with hydropathic measures, and has thus obtained excellent results. My own experience is confirmatory of this. As to the form of electricity best adapted to the relief of constipation, there is also a difference of opinion. Older writers, as Duchenne, Hoffmann, and others, used the fara- dic current only, and Erb, upon physiological grounds, seems to hold it to be the best. Rockwell expresses himself 1 Med. and Surg. Electricity, B. & R., 1888. 2 Centralblatt f. innere Medicin, 1887, p. 457, "Die Behandlung der chron. Stuhlverstopfung." 8 Wiener mediz. Prexse, loc. cit. * Ueber die habituelle Obstipation u. ihre Behandlung mit Electricitat Massage u. Wasser, Wiesbaden, 1890. TREATMENT OF CONSTIPATION DUE TO ATONY 285 very clearly upon this point: ''Both the galvanic and faradic currents may be used, but my preference has been and is for the faradic. Its powerful mechanical and lim- ited reflex effects seem to be better adapted to restore the impaired irritability of the muscular coats," Leubusher, in the report referred to, states that he has found the galvanic current the more effective, and Shoemaker also claims better results from the galvanic than the faradic currents. There are two methods by which the electricity may be applied, whatever form of current be selected : I. The percutaneous method (where both poles are with- out, upon the external surface). 11. The internal method (where one or two poles are within the rectum). These methods have a further subdivision as regards application. (a) Unipolar method (where one pole is placed over the seat of disease, i.e. the bowels, the other over an indifferent point). (b) Bipolar method (both poles over region or point affected). In the abdominal application of electricity the patient should always be in the horizontal position. Faradic Current A. Percutaneous Method. Procedure of Erh. The anode ^ (large electrode 10 to 12 cm. long, 5 to 6 cm. ^ Anode, positive pole. 286 CONSTIPATION IN ADULTS broad) is placed stabile' over the upper lumbar verte- brae; the cathode- (medium-sized electrode, plate 5 to 6 cm. square), labile/* is moved over the whole abdominal surface. Over the region of the caecum it is pressed in more deeply and firmly * and retained there, stabile, for a few moments ; it is moved over the colon, down over the sigmoid flexure, where it is again pressed in and held stabile for a few seconds. Then the electrode is moved in circles around the navel, and spirals or circles described with it over the whole length of the abdominal surface. Then the electrodes are placed in the opposite loins, stabile, and the current allowed to flow between them, with occa- sional reversals of current direction. The current should be sufficiently strong to call forth strong contractions of the abdominal muscles. In one way, however, it may be better to avoid these contrac- tions, as they prevent the deeper penetration of the cur- rent. The motor points must then be avoided. Duration of sitting, from three to ten minutes.^ In my own experience I have learnt to prefer the bipolar application, for the reason that I believe the desired result is obtained more quickly in this way than otherwise. The cathode (small electrode) is placed stabile over the caecum, and the anode moved over the tract of the ascend- ing, transverse, and descending colon over on to the sigmoid flexure, where the electrode is held for a few 1 Stabile, when the electrode is held fixed, immovable. 2 Cathode, negative pole. 8 Labile, moving, when the electrode is kept moving around. * Firm pressure increases the conductivity of the skin ; it is better mois- tened and in better apposition with the electrode. 5 Erb, loc. cit. TllEATMENT OF CONSTIPATION DUE TO ATONY 287 moments pressed down more firmly; then it is moved downward and inward to about the region of the annulus of the rectum, where it is again held stabile and firmly for a few moments. Whilst the anode is thus held stabile, the current direction is occasionally changed. This whole movement is repeated, beginning again at the caecum, and then an interval of rest allowed. (If the battery have no "reverse" attachment, the repetition is made with the poles changed.) Then beginning again at the caecum, the two poles, both labile and both stabile, are carried over the tract of the large bowel in this wise : The cathode is placed over the caecum at its lowest point, and the anode in advance of the former about a hand's breadth, and they are continued in this relation to each other throughout the whole move- ment. The two poles are held stabile for a moment, then a slight advance about two fingers' breadth slowly made and the poles again held stabile, and this alternation of movement and rest continued until the whole gut has been gone over with both poles. This is repeated, and then an interval of rest allowed. To close the sitting, the anode (large electrode) is placed over the lumbar vertebra stabile, and the cathode (small electrode) moved in circles around the navel, smaller, and then larger, and finally spirals and circles described with it the whole length of the abdominal surface. The strength of the current used : sufficient to produce strong contraction of the intestine at the anode. The current of the primary coil with rather long inter- ruptions is to be preferred, according to Sperling.^ ^ Pierson-Sperling, Elektrotherapie. 288 CONSTIPATIOJ^ IN ADULTS The duration of the sitting, at the outset of the treat- ment, should not be longer than four minutes ; gradually it is increased in length for subsequent sittings to ten minutes. B. Internal Method. Procedure of ^r&. — Later on (after proceeding first as above), to obtain, as he says, a stronger effect, Erb resorts to this procedure : A metallic electrode, insulated up to its olive-shaped point (anode), is introduced six to eight centimetres deep into the rectum. This, usually, causes no pain or disagreeable feeling; at most, when the cathode is in the rectum, a slight tingling, or pricking, or a feeling of heat. The other electrode is moved over the abdomen as already described above. The current should be occasionally reversed (or the electrodes changed when the apparatus is not provided with the necessary contrivance therefor) so as to allow the cathode to act upon the rectum, i.e. more directly upon the bowel. The measure of intensity of the current is, here also, strong contraction of the abdominal muscles. Duration of sitting : three to ten minutes.^ De Watteville ' proceeds in the same manner ; so also does Rockwell.^ The latter also favors the bipolar internal method by means of a double electrode. This latter procedure is only made use of with currents of quantity. His reason therefor is this : Induction currents of tension, when applied to mucous surfaces, act very mildly, both on the motor and sensory nerves. The parts become rapidly 1 Loc. cit. ^ A Practical Introduction to Medical Electricity. 8 Loc. cit. TREATMENT OF CONSTIPATION DUE TO ATONY 289 Rectal Electrodes. Bipolar-rectal Electrodes. 290 CONSTIPATION IN ADULTS tolerant, so much so that even currents of great strength may be passed, and the patient remain totally unconscious thereof. Induction currents of quantity, however, applied to surfaces that offer little resistance to their passage, have a much more powerful influence, and are therefore to be preferred when the purpose is to excite muscular contraction. In order, therefore, that the resistance be reduced to the minimum, both poles should be introduced into the rectum. The parts do not be- come tolerant of its influence as the applications are continued. The use of this latter current requires the exercise of the greatest caution, as excessive pain is caused by strong applica- tions. In addition to the local treatment, and as often sur- passing it in effectiveness, Rockwell recommends general faradization.^ It consists in sponging the whole or the greater part of the body, first one arm, then the neck, then the thorax, then the abdomen,^ with one electrode, whilst the other is held stabile at one of the terminal points of the body, as a plate beneath the buttocks (patient sitting on it 3), as a plate pressed or held against the sacrum, or as a plate on which the feet rest. The difficulty of the application lies in the proper regulation of the current necessary to stimulate fully without causing actual pain in the different parts over which the sponge is being carried ; this is best learnt by experiment upon oneself.* Rockwell 5 places the patient in the sitting posture upon a stool with his bare feet upon a copper plate attached to the negative pole of the battery. The best form of electrode that is applied over the body is a brass ball about one inch in diameter, and this is enveloped in a soft wet sponge about six inches in diameter. The moistened hand of the operator can be used as the labile electrode, and is 1 Loc. cit. 2 Pierson-Sperling, Elektrotherapie, Leipzig, 1893. 8 Ibid. " De Watteville, loc. cit. Loc. cii. TREATMENT OF CONSTIPATION DUE TO ATONY 291 the most agreeable to the patient, and next to it is the electrode just described. The sponge can be folded tightly over the brass ball so as to make a small electrode, or loosely, so that almost its entire surface may be applied. ^ The duration of the sitting should not be over ten minutes at the outset of the treatment, giving the abdo- men four minutes and distributing the remaining time over the other parts. Gradually the length of the sitting may be prolonged, and the other parts (except the neck, for which two minutes suffice) given equal time with the abdomen.^ As regards the strength of the faradic current to be used in the various methods, the views of Erb have already been given. Rockwell ^ says that it may be left to the sensations of the patient. " Whatever is borne without great discomfort is safe to use." According to Lehr, the faradic bath is of benefit in constipation.* Galvanic Current A. Percutaneous Method. — The anode is placed upon the back over the lumbar vertebrae stabile ; the cathode, both stabile and labile, over the whole abdomen, making numerous closures and frequent reversals over the whole extent of the intestinal tract. Then the splanchnic nerves are galvanized along the thoracic sympathetic, thus : The anode is placed over the ^ Rockwell, loc. cit. 2 Pierson-Sperling, loc. cit. 8 l^c. cit. * " Ueber electrische Biider," Verhdl. des II. Congress, f. innere Medizin, Wiesbaden, 1883. Die hydro-electrischen Biider, ihre Wirkung, etc., Wies- baden, 1883. See also "A New Electric Bath," Gartner, Wiener klin. Wochenschri/t, 1893, 34. 292 CONSTIPATION IN ADULTS lumbar vertebriB stabile, and the cathode stabile and labile on either side of the spine from the fifth to the twelfth dorsal vertebra. Duration of the sitting, three to five minutes.^ Erb, in obstinate cases, uses the galvanic current for a few moments as described, and follows it with faradization.^ B. Internal Method. — One pole is placed in the rectum and the other (indifferent pole) upon the abdomen. Rockwell teaches that with the galvanic current the cathode should invariably be placed within the rectum.* Leubusher" also advocates this. Shoemaker places the cathode in the rectum, and the other pole is pressed against the perineum.^ The strength of the galvanic current should not exceed, according to Rockwell,' two to three milliamperes even when used with constant interruptions; but when it is used continuously, without interruptions, one to two milh- amperes will amply suffice. Shoemaker advises that the strength of the current be about one milliampere, rather less than more, so that at the outset the patient will not feel any current at all pass- ing. However, in the course of fifteen or twenty seconds he will begin to feel the cold electrode in the rectum growing warmer and becoming gradually heated to the point of painless tolerance. Shock or even abrupt transitions in the strength of the current are prejudicial to success. a Erb, loc. cit. ^ Ibid. « Loc. cit. * Loc. cit. 6 Medical Bulletin, June, 1890. 6 Bigelow, International System of Electrotherapeutics. ^ Sremaker. loc. cit. International System of Electrotherapeutics. TREATMENT OF CONSTIPATION DUE TO ATONY 293 When currents of greater strength are used with the internal method, the closure ' of the current must not be of too long duration, as otherwise an eschar might be pro- duced. It is better, then, to make frequent reversals, and to have the several closures of the current of short duration.'^ Method of Boudet (de Paris). — A litre of salt water is first thrown into the rectum ; then the electrode, best in the form of a stylet in a thick rubber sound, is introduced. The other electrode (400 cm. square) is placed upon the back. Currents of ten to fifty milliamperes from five to twenty minutes, stabile, or (when the stronger currents are used) frequent reversals and interpolated pauses.^ Galvano-Faradization Erb* recommends very highly galvano-faradization as introduced into electrotherapeutics by De Watteville, a method of treatment in which, as the name indicates, both currents, the galvanic and the faradic, are sent simul- taneously into the body. De Watteville' s procedure in constipation is this : A very large electrode (plate) is fixed to the back, whilst another is made to rest first upon the umbilical region and then carried round the whole course of the colon.^ Erb places the anode upon the back and the cathode upon the abdomen. Strong currents are used with numer- 1 Both poles in contact with the body and the current flowing between them. ^ Rockwell, loc. cit. 3 Progres Medical, 1887, No. 67. Erb's Handbuch, loc. cit. * Erb, Handbuch der Electrotherapie. 8 De Watteville, loc. cit. ' 294 CONSTIPATION IN ADULTS ous voltaic alternatives. 1 When the subject is very fat, the electrodes should be pressed down firmly so as to diminish the resistance between them and the viscera. Duration of the sitting, eight to ten minutes.^ Broese ^ uses very large electrodes, 400 sq. cm., both for the back and the abdomen. The strength of the faradic current of the secondary coil is raised to its utmost, whilst the galvanic current is gradually increased to fifty or seventy-five milliamperes. Duration of sitting, usually seven minutes. He occasionally resorts to massage in combination with the electrical treatment. Courtade :* Instruments necessary: a large tin plate covered with chamois skin ; one cylindrical carbon electrode 4 cm. long and 8 mm. in diameter, firmly attached to one extremity of a semi-solid insulated conductor ; one circular carbon electrode 4 cm. in diameter, covered with chamois skin ; a faradic bat- tery with two coils, one of fine, the other of coarse wire ; a gal- vanic battery ; an induction (influence) machine. His procedure is divided into two parts (a) Introductory treatment ; (b) Treatment proper. A. Introductory treatment: General franklinization. The patient receives a static bath, of a quarter of an hour's duration, with the generalized breeze and the application of static sparks to the abdomen. 1 Reversal of the current by means of the commutator — the pole pre- viously negative becomes positive, and the previously positive becomes negative. 2 De Watteville, loc. cit. 8 Festschrift z. Ehren d. 25 jahrig. Jubilaums des Geh. R. Prof. Dr. Meyer in Gottingen. Pierson-Sperling, loc. cit. * Joxirnal des Practiciens, 1896, No. 47. Journal of Electro-Therapeutics, April, 1897. TREATMENT OF CONSTIPATION DUE TO ATONY 295 B. Treatment projoer : The cylindrical carbon electrode is introduced into the rectum as high up as possible and the large (tin) plate placed over the Sigmoid flexure (if the trouble is supposed to be located in the caecum, it is placed over this). The cords are connected with the faradic battery, and an induced current from the coarse wire coil allowed to pass through for three or four minutes. The two electrodes are now disconnected from the faradic and attached to the galvanic battery and a current allowed to flow in ; not a continuous current, but one, now in the form of rapid waves, now with quick inter- ruptions. The waves are created by running up rapidly from zero to 20, to 40, M.A. and back again. The cur- rent is interrupted by rapidly making and breaking it. As to the intensity of the current, though this should depend in a great measure upon the sensibility of the patient, it should not in any case surpass 40 M.A., espe- cially not when interruptions are made. Though the carbon electrodes are less apt to produce eschars, never- theless a too prolonged contact should be avoided ; the position of the electrodes should be changed from time to time. It is immaterial to which pole the rectal electrode is first attached, for the current should be frequently alternated. Duration of treatment with galvanic current: eight to ten minutes. The treatment is concluded in this wise : the large (tin) plate is placed over the dorsal or over the lumbar vertebrae (according to the indications in the case) ; the rectal elec- trode is withdrawn, removed, and the circular carbon electrode attached to the pole and promenaded over the abdomen. The cords are now detached from the galvanic, 296 CONSTIPATION IN ADULTS and connected with the faradic battery, and a current from the fine wire coil allowed to flow in, — this makes a sort of electrical friction of the abdomen. Three sittings per week. The rectal electrodes as commonly found have already been figured. Leubusher thinks that they are but ill adapted to the purpose, and prefers to use a conically pointed sponge electrode. I use an ordinary olive pointed electrode for the rectum, and externally an ordinary elec- trode, plate or cup, covered with absorbent cotton, and moistened. Absorbent cotton is by all means a much more desirable covering for electrodes than sponges. Frequency of Treatment. — Ordinarily, when the con- stipated state is but of a few months' duration (four to eight months), a sitting every other day will suffice. In very obstinate cases of long duration (one year and over) a sitting should be had every day at the outset of the treatment, and then, later on, as improvement manifests itself, a treatment every other day will be all that will be required. When the sittings are had daily, I confine myself on the alternate days to rather feeble currents. Movements of the bowels may set in already after the second or third sitting; at other times not until after very many applications. Again, with some the bowels will move shortly after the application, two or three hours or even a briefer period; with others it will be ten or fifteen hours after the sitting. The Duration of the Treatment. — The time required for the treatment of constipation with electricity is from two to six weeks. Cases have been reported where two or TREATMENT OF CONSTIPATION DUE TO ATONY 297 three applications permanently relieved the patient/ and otliers again where it required many sittings, nineteen or twenty, or more, to obtain the desired effect.''' Though it is not the purpose here to go into the physio- logical action of the electric current, there is one point that must be mentioned here, one to which Leubusher, I believe, first called attention, and which is of some clinical importance. It is this : Leubusher observed in the series of cases treated by him that the intestinal secre- tion, which previously was seemingly deficient, was greatly increased by the stimulus of the current.^ Special Indications and Selection of Current. 1. The constipation dependent upon chronic spinal diseases and chronic cerebral affections (other than those of an apo- plectic character), galvanic current. 2. Constipation dependent upon cerebral apoplexies, /amcZi> current. For other forms of constipation : In constipation dependent upon atony, or paralysis of the intestine, t\\Q faradic current. In constipation concomitant with neurasthenia, the faradic current and general faradization. In constipation with hysteria, and in spasmodic constipation, the galvanic current and central galvanization. In hysteria we may also resort, for the general condition, to franklinization in the form of bath * or douche,^ a method of treatment with which some success has been reported.^ Locally, for the constipation, the galvanic current is employed. Scheme of electrical treatment of constipation due to atony : 1 Rockwell, loc. cit. * The patient upon the insulated stool. 2 Erb, loc. cit. e By means of the crown-like electrode. ' Loc. cit. 6 Pierson-Sperling, loc. cit. 298 CONSTIPATION IN ADULTS First sitting. Percutaneous application (unipolar or bi[)olar method). Second sitting. Percutaneous application. Internal application (unipolar method), the time divided equally between the two forms of application. TJiird sitting. Internal application (unipolar method) two- thirds of the time. Percutaneous application (unipolar method), and so on. We will avail ourselves, in connection with the elec- trical treatment, of the benefits to be derived from a prop- erly regulated diet, as described above, and from dietetic exercise. CHAPTER XX MEDICINES The remedies that we can call in to our assistance are but few in number, the whole group of cathartics being, as already said, excluded. They are nux vomica and its alkaloid strychnina, and physostigmatis faba (Calabar bean), of two different groups of medicinal agents. Both provoke peristalsis, though their mode of so doing differs. Nux Vomica {Strychnos Nux-vomica). Group : excito- MOTORS.^ Tinctura Nucis Vomicae (tincture of nux vomica). — This may be administered in doses of five to ten drops three times a day, just before meals. If there be symptoms of dyspepsia, especially pressure after eating, I give it after meals, — immediately thereafter, or from one-half to one hour later. I have obtained very excellent effects with very small doses frequently repeated, guttas i in a tea- spoonful of water every two hours. I generally begin with a small dose, guttoB iii in a teaspoonful of water three times daily, before meals, and increase by two drops every other day, until the maximum dose of fifteen drops is reached. I then descend the scale, diminishing the dose by two drops every other day, until the initial dose is 1 H. C. Wood, Therapeutics, its Principles and Practice, 1894. 299 300 CONSTIPATION IN ADULTS reached. Then the administration of the remedy is sus- pended, to be resumed again in two weeks or ten days, if the indication therefor still exist. If there be much flatu- lence, it will be well to combine the nux vomica with Fowler's solution : ^6 Tinct. Nuc. Vomic. 3 iii Solut. Fowleri 3 i M. Sig. Arsenical preparations, especially the one named, have apparently a marked influence in inhibiting the develop- ment of flatus. Strychnina (strychninae sulphas; strychninas nitras). — Some prefer to administer strychnine. It may be given in pill form, in doses of one-sixtieth to one-thirtieth of a grain, three times daily, after meals. I have had very good results with doses of one one-hundredth of a grain, well triturated with sugar of milk, taken every four hours. If there be indigestion due to insufficiency of hydrochloric acid in the gastric secretion, the strychnine can be com- bined with the acid, thus : Acid. Hydrochloric, dilut. Sss Strychnina. Sulphat. gr. = (yV-?V P®^ ^ose) M. Sig. Ten drops three times daily, after meals (it can be given, if thought preferable for any reason, before meals). As a rule, it is more convenient for this class of patients, who generally follow their vocations as usual, to take their medicine three times daily; a more frequent administration necessitates the carrying of the medicnie, and that is very inconvenient. MEDICINES 301 2. Physostigmatis Faba {Physostigma venenosum, Cala- bar bean). Group: depresso-motors.^ Tinctura Physostigmatis Fabae (tincture of Calabar bean) can be administered in doses of ten drops three times a day. I prefer to begin with a smaller dose, five drops, and gradually to reach the maximum dose of twelve minims three times daily. Extractum Physostigmatis Fabae (extract of Calabar bean). Dose (gr. j-V-^) ^ Extract. Physostigmat. Fab. grs. 1|^^ Glycerinse 3 v M. bene Sig. Three to six drops, three to four times daily. It can be given also in pill form. Some combine the physostigma with belladonna and nux vomica,^ others with belladonna and ergot, thus : 1^ Extract. Physostigmat. Fab. gr. ^ Extract. Belladonna. grs. ii Extract. Ergota. grs. xii M. ft. Mass. et divid. in pillul. sequal. No. VI. Sig. One pill at bedtime.^ 1 myself never give belladonna in this form of consti- pation and never combine the remedies mentioned ; I pre- fer to give them individually and alternately, believing that a better result can be thus obtained. Physostigmine, Syn. Eserine (alkaloid of Calabar bean), Physostigminae Salicylas, can be rubbed up with sugar of ^ H. C. Wood, Therapeutics, its Principles, etc. 2 Brunton, Text-book of Pharmacology, Therapeutics, and Materia Med- ica, Philadelphia, 1888. » Treat's Annual, 1890. 302 CONSTIPATION IN ADULTS milk. The dose, according to Brimton/ is one-sixteenth to one-twelfth of a grain. Helbing, in his Modern Materia Medica, gives as the dose for administration one one-hun- dredth to one-fiftieth of a grain. The sulphate is used in veterinary practice only. It is there given hypodermatically in colics. Ergot has also been warmly commended for use in atonic constipation.^ Dr. Granzio reported two cases of atonic constipation, resulting from the prolonged abuse of purgative medicines, in which excellent results were obtained with ergot. Three doses, of ten grains each, were given at intervals of two hours, and were followed by a full and free evacuation. The next day an evacua- tion occurred spontaneously. The ergot was now admin- istered in smaller doses, and after a few days the patients were discharged well.^ It may be given alone or in combination with bella- donna, with Calabar bean or with nux vomica. Zinc Sulphate was recommended by older physicians for obstinate constipation. It has been used as a tonic in flatulence and flatulent distention of the colon.* It is best administered in the form of a pill made with bread crumb, or it can be made into a mass with some indifferent extract like Gentian or Taraxacum and put into a capsule. Dose, two to five grains, three times a day. It is said to be of service in those suffering from want of tone, in the weak and debilitated. 1 Loc. cit. ^ Brunton, loc. cit. • 3 El Siglo Medic, November 4, 1883. Allgemeine mediz. Central- Zeitung, May 24, 1884. New York Medical Record, 1884. * Brunton, Pharmacology, Therapeutics, and Materia Medica, 1888. MEDICINES 303 Case 39. Mr. Baly reported the following case to the London Medical Society : A young lady came under his care in the autumn of 1853, anaemic and of feeble constitution ; had been troubled with habitual constipation from childhood ; from the age of fifteen had constantly had recourse to large doses of aloetic aperients, and for many years had not had any action of the bowels without their aid. Latterly, she had frequently used injections, but these now fail frequently, and, at the present time, she generally obtains relief every three or four days by a dose of blue pill and colocynth at night, followed by an enema in the morning ; the latter frequently repeated. She complains of great debility ; inability to make exertion, mental or bodily ; temper irritable ; spirits depressed ; pulse feeble ; catamenia regular, but pale ; frequently suffers from cold extremities ; appetite small. When the bowels have not acted for three or four days, she suffers from a sense of fulness and distention of the abdomen; she frequently, after an evacuation, suffers for some hours from severe prostration. In this case he revived the treatment proposed by Dr. Strong in 1842, it being evident that the continued employment of any form of aperient would be hurtful. Having, as a preliminary measure, cleared out the bowels with a dose of blue pill and colocynth, followed by an enema, he ordered sulphate of zinc, five grains, bread crumb sufficient for a pill, to be taken three times a day immediately after each meal. This was continued for ten days without causing sickness and with decided relief to the abdominal dis- tention ; the appetite improved, the listlessness decreased. No evacuation occurred from the second day till the tenth, when the following was administered : Calomel, four grains, extract colo- cynth CO., six grains; make a pill to be taken at bedtime, to be followed by a black draught in the morning. On the day following this the bowels acted spontaneously, and, from that time until now, nearly twelve months, have been relieved daily without aperients or enemata. The use of the sulphate of zinc was continued for three weeks, and then gradually exchanged for sulphate of quinine. A curious fact deserves notice in this case. For some time after the discontinuance of the enemata, 304 CONSTIPATION IN ADULTS the patient was not sensible of the action of the rectum during the passage of the faeces. Other cases were cited in support of the treatment, the use of which he would limit to cases dependent upon a want of tone.^ Ammonii Chloridum {Ammonium muriaticum; Chloride of Arnmonium). — The muriate of ammonia will be found of much service in those cases where, the faeces con- tinuing hard and dry and lumpy, there is evidently a deficient secretion of mucus as a result of glandular atony (from prolonged pressure of the accumulated faeces upon the mucous membrane, from general debility), or even perhaps of glandular atrophy, to a certain extent (from protracted intestinal disease, as enteric fever, acute or chronic inflammations). That it stimulates the action of the muciparous follicles of the mucous membrane is a matter of long observation as regards the bronchial mucous membrane, and that it acts in the same way upon the intestinal mucous mem- brane, I can affirm from my own clinical observation. Brunton makes mention of this action in his Pharma- cology and Therapeutics.^ JDose and Administration. — It may be given in doses of five to ten grains three times a day. It is best adminis- tered in the intervals between the meals. It can be given in the form of a tablet, or in powder to be dissolved in water or milk. 1 Lancet (London), 1854, Vol. II., p. 381. 2 A Text-book of Pharmacology, Therapeutics, and Materia Medica, by T. Lauder Brunton, M.D., etc., Philadelphia, 1888. CHAPTER XXI I EFFECTS OF TREATMENT. II. COMPLICATION 1. Effects of Treatment. — These various methods of treatment can be employed singly or combined, as already indicated. However, it will be found, I believe, that a combination of two or more of these methods will greatly enhance the efficacy of our efforts. Thus we may com- bine massage with electricity as recommended by Noth- nagel/ or with electricity and medication; or massage and hydropathy, adding thereto the administration of certain medicines as may appear to us indicated. We may combine hydropathy with electricity, or with medica- tion, or with electricity and medication. No doubt, in many instances, we will be governed in our selection of the method or methods of treatment by the surroundings and conditions in life of the patient. Much, also, will undoubtedly depend upon the familiarity of the physician with one or the other plans of treatment, or his ignorance of them; this last factor should be eliminated. The phy- sician should be acquainted, and equally well acquainted, with all the mechanical measures employed, in so far, at least, as the treatment of constipation is concerned. No matter what plan of treatment we select, this one important fact must always be borne in mind : that the ^ Wiener mediz. Presse, loc. cit. 305 306 CONSTIPATION IN ADULTS dietary regulations and the rules as to exercise are indis- pensable to success. In fact, we may, with these alone, not infrequently achieve astonishing results. I have seen quite a number of cases of constipation of long standing that presented themselves at the dispensary completely cured by diet and exercise alone. By means of these vari- ous regulations and measures we will be able to restore to the intestinal muscles their lost vigor ; we will be able to reduce dilated or dilated and hypertrophic intestines to their normal calibre, or nearly so. We will be able to overcome the unpleasant head symp- toms frequently produced by constipation and already de- scribed above. In this respect massage of the abdomen, with faradization of the head and nucha, will prove of the greatest benefit. Even before we have succeeded in re- storing the normal intestinal function, we may have effected a disappearance of the head symptoms, as I have seen in a number of instances, and for which relief alone patients are very grateful. II. Complications. — In a number of cases of atonic constipation I have discovered a marked atony of the stomach. This can be recognized hy the splashing sound (pldtsohern) obtained on palpating the stomach from the epigastrium down- ward, and from the cardia to the pylorus. It may also be obtained by shaking the patient from side to side. In severe atony the region of splashing sound extends as far down as the navel. This is a complication that is exceedingly troublesome, as it interferes very much with the treatment, in so far that the dietary regulations required for the one are diamet- I. EFFECTS OF TREATMENT. H. COMPLICATION 307 rically the opposite of those necessary for the other. My plan of treatment here is to secure first the regular action of the bowels, not paying any attention to the condition of the stomach in the regulation of the diet, but of course treating its atony by massage, electricity, hydropathy, etc. Then, when the bowels are acting fairly well, the dietary regulations requisite for the relief of the stomach (and without which much cannot be accomplished) are pre- scribed and enforced. CHAPTER XXII TREATMENT OF CONDITIONS RELATED TO ATONY I. Ileus ; ivith special reference to the forms named in the chapter, "Consequences of Constipation." For illus- tration, see Case 25. Most frequently seen in old people. If the rectum be loaded, the first step will be to empty this by means of the finger or scoop, if the faecal matter be very hard ; if not, by the use of rectal injections, cold or hot. When this has been accomplished, or if the rectum be empty, the accumulation being located higher up, we will resort to large injections, allowing a quart of water, at a temperature of 80° F. to 90° F., to flow in at a time. Where there is much flatus, as indicated by the marked tympanitis, we will add to the water either spirits of tur- pentine (3 i to the quart of water) or milk of assafoetida^ (5 ii-iii to the quart of water). These two agents I have found most effective for the removal of flatus. For the administration of these injections the patient lies down upon his back upon the bed or couch, a pillow or two is placed beneath the hips, so as to give the lower half of the trunk the form of an inclined plane with the downward inclination to the diaphragm, and the reservoir is elevated to a good height,^ — three or four feet, — so 1 Made from the fresh gum and not with the exsiccated powder resorted to so frequently by apothecaries. 2 There need be no fear of injury from a reasonable amount of pressure. This is clearly demonstrated by the investigations of R. E. MuUer, "Entero- .308 TREATMENT OF CONDITIONS RELATED TO ATONY 309 as to obtain sufficient force to break down the impacted and obstructing mass. We can add still further to the effectiveness of the clyster by increasing the length of the rectal point of the syringe (which are all too short, as has already been said) by means of an O'Beirne rectal tube or a section of a stomach tube. The patient should be persuaded, coaxed, or even begged to retain the injection as long as possible, so that it may exercise its softening and thinning action upon the indurated mass to the largest extent. The injections should be repeated at intervals of three or four hours. When the accumulation is not very large, the ileus being rather of the paralytic form described, we may give two or three injections with the water at a higher and lower temperature alternately, as already set forth, at intervals of fifteen to thirty minutes, and then rest for three or four hours.^ In the intervals we may administer small doses of olive oil, 3 i-ii every two hours, with an equal quantity of glycerine or honey. (This makes the oil more palatable and more readily taken.) In the place of water we may use oil for the injections, according to the method of Fleiner.^ clyses ill the Summer Diarrhoea of Children, etc., with the Results of Labo- ratory Investigations," Therapeutic Gazette, 1893. ^ This procedure can and should be resorted to in obstruction from intus- susception volvulus, etc., upon the basis first laid down in my paper on this subject in the American Journal of the Medical Sciences, January, 1886, and reiterated in an editorial in the Archives of Pediatrics, November, 1895, namely, either that the injection will quickly relieve the obstruction or its failure be a positive indication that operative interference is necessary and should not be delayed. ^ See chapter, " Oil Injections." 310 CONSTIPATION IN ADULTS We may further aid our efforts, and add to the vigor of the peristaltic movement excited, by the administration of strychnine, preferably in small doses, or the tincture of nux vomica, two drops every one or two hours. II. Intestinal Paralysis, due to the exhaustion of mus- cular vigor in the large bowel by reason of over-excita- tion or over-stimulation by strong cathartics.' In persons of constipated habit, we may have at times a paralysis of the intestinal tract come on very suddenly. The bowels refuse to act. The remedies which have usually provoked evacuation are inefficient, even in increased doses. Still more powerful agents are equally without effect. The condition resembles very much intestinal obstruction?' Treatment. — Electricity, external or internal method, or both combined. Hydropathic measures : the douche to the abdomen ; the general rain-bath ; the clysters, hot or cold. Medication, addressed to the nervous system, or to both the nervous and muscular system ; nux vomica or strych- nine or physostigma, alone, or combined with ergot or with other agents having a similar action ; I have some- times given it with quinia. In the condition described (or in analogous conditions from chronic central lesions) I like to give the strychnine in small, but frequently repeated, doses, one one-hundred and twentieth to one one-hundredth of a grain, well rubbed up with sugar of milk, every four hours 1 Other forms have been already referred to. 2 See Des Pseudo-Etranglements, by Dr. Henri Henrot, Paris, 1865. Treves, loc. cit. "Pseudo-Intestinal Obstruction," by H. Illoway, M.D., MedicLl News (Philadelphia), August 28, 1886. Rosenheim, loc. cit. 8 The trituration must be very thorough. TREATMENT OF CONDITIONS RELATED TO ATONY 311 III. Atony of the Rectum. Atony of the Pouch of the Rectum} — It hcas already been stated that the various segments of the large bowel can be distended as a result of atonic constipation, and that the rectum forms no ex- ception thereto. The whole rectum is then involved in the distention, and usually the parts above it as well. Under the term atony of the rectum, however, we have described to us a condition wherein the ampulla of the rectum alone is distended, the rest of the rectum, as also the parts beyond, retaining their normal character. Constipation of an obstinate character is a feature of this condition. As to the causes of this dilatation, I may say that I am not of the opinion that the most frequent etiological factor is a neglect of the calls of nature. I do not be- heve that ordinarily, even with a marked degree of atony, the faeces, once so low down, can be held there, and this for reasons already set forth in the chapter on the physi- ology of defecation. The most frequent causes, in my opinion, are such pathological conditions of the rectum as tend to make defecation exceedingly painful, strong contractions of the sphincter being then provoked and the fseces forcibly held back. These conditions are : Fissure of the anus. Haemorrhoids. Hypersesthesia of the lowest segment of the rectum. Painful conditions of the genito-urinary tract. It may also result as a consequence of the great debility ^ See the various works on Diseases of the Rectum, Kelsey, Mathews, Cripps, Van Buren. In most works under the head of "Impacted Fteces." 312 CONSTIPATION IN ADULTS following protracted exhausting diseases, as typhoid fever, long-continued remittent fever, etc., when the patient does not possess sufficient strength to force inspissated and scybalous fteces through the sphincter. Here, the rather concentrated character of the aliment, containing but very little residual matter, is also, no doubt, an important factor. Furthermore, the greatly lowered nervous irritability, and the fact that such patients pass most of their time in the lying or sitting posture, greatly favor the retention and the accumulation of faeces at this point. An anaesthetic condition of the rectum as may occasion- ally be met with in the neurasthenic, and more frequently in the hypochondriac and the melancholic, tends to its development. It is very much favored by the constant use of tepid or warm injections to which so many persons, especially females, are addicted. Old age, with its debility, its obtunded sensibilities, and the tendency to sit or lie down a great part of the time, favors the production of atony of the rectum. It can thus occur at all periods of life, and in persons of every condition. Most commonly, however, it is met with in delicate females with lax muscular fibre, and in persons of very advanced age. It is said to be met with in delicate children. The dilatation of the ampulla may reach an enormous extent. Generally the pouch will be found to contain large masses of faeces indurated to stony hardness. The pressure made upon the mucous membrane of the rectum may set up a catarrhal irritation with the charac- teristic discharge. TREATMENT OF CONDITIONS RELATED TO ATONY 313 The symptoms of this condition have especial reference to the rectum. A sense of fulness or weight therein, with sometimes a sensation as if a weight were pressing down the parts. Frequent desire to go to stool which, when gratified, results in the discharge of a few small, hard, scjbala, or of a little fluid faecal matter which may lead us to a wrong diagnosis. Pain, due to spasm of the sphincter, frequently attends the stool. With these we may have symptoms of irritation of the various organs of the genito-urinary tract, excited by the pressure made upon them by the indurated and hardened faecal mass. Sometimes we have only constipation, without any other especial manifestation to indicate to us the seat of the difficulty. Examination of the rectum with the finger will disclose the presence of a large quantity of hard, firmly packed faeces, and when this has been evacuated, the finger will sweep about in a large, sometimes immense, pocket, as it were. Examining with the speculum, the pocket will be found filled sometimes, with enlarged folds of loose mucous mem- brane which have a tendency to pass downward, with the efforts at stool, between the two sphincters, and thus narrow and even block up the exit against the faecal bolus. For the relief of this condition we will firstly remove or render innocuous the cause or causes that have pro- duced it. If fissure of the aiius be present, we will incise it as advocated now by the majority of writers, or we may treat it with forcible dilatation. Haemorrhoids will receive the proper attention ; etc. 314 CONSTIPATION IN ADULTS We will cleanse the rectum thoroughly of all scybala or faecal accumulations. We will then see to it that the patient has daily a full and free evacuation. To accom- plish this we may resort to the rectal injection of glyce- rine 5 ss-i, or to the glycerine suppository (which I do not think "as effective), or to the injection of a small quantity of very cold water.^ This latter has this additionally in its favor, that it stimulates both nerve and muscle of the part, and thus tends to invigorate it. It will also aid in dispelling the turgidity or congestion which is almost always present in atony of the rectum. To this may be added the cold douche to the abdomen or the general rain-bath. We will further tone up the general abdominal vigor by massage, and for the special condition under consideration, we will " beat the sacrum," as already described.^ We can employ electricity both percutaneously and internally. The faradic current should have the prefer- ence. In addition to all this, we will resort to the proper medication to give tone to the system. We may give nux vomica in extract, one-half to one grain in a pill once daily, or after the fashion already described. Strychnine is, I think, specially indicated, alternating with physostigma where the condition seems to require it. Bark (compound tincture of cinchona) with nux vomica or strychnine or the hypophosphites with strychnine will be given, according to the indications. With these measures all can be accomplished that is requisite, and astringent injections and the use of purga- 1 See section on " Hydrotherapy." ^ See section on « Massage." TREATMENT OF CONDITIONS RELATED TO ATONY 315 tives, as were formerly advocated, can generally be dis- pensed with. Bretonneau recommended as a local injection to induce con- traction of the part : Extract. Rhatanise (Kramerise) 3 ii Spirit. Vin. Rectilicat. 3 v Aqu. Pura. 5 iv Misc. This prescription is also highly commended by Trousseau ^ for the treatment of anal fissure. Bodenhammer claimed good results from ]^ Acid. Tannic. 3 i Claret Wine § iv Misc. He has also used with success decoctions of white-oak bark and alum, as also the decoction of galls. With these astringent injections the use of purgatives, as already mentioned above, is combined. Bodenhammer gives a pill composed as follows : 5 Extract. Aloe 3 ss Extract. Nuc. Vomic. 3 i Extract. Hyosciam. grs. xv Ferr. Sulphat. grs. x Ole. Caryophyll. gtt. v M. ft. pillul. No. XXX. Sig. Take one at dinner or at bedtime. Van Buren prescribed this pill : 5 Ferr. Sulphat. Exsiccat. Quinia. Sulphat. aa 9 ii Extract. Nuc. Vomic. Extract. Aloe aa grs. xii Misc. ft. pillul. No. XL. Sig. One pill three times a day. ' Clinical Lectures. 316 CONSTIPATION IN ADULTS Or a prescription, as follows, is given : 1^ Extract. Aloe Extract. Hyosciam. Extract. Nuc. Vomic. Ole. Anis. aa 3 i grs. iv gtt. iv M. S. A. et ft. pillul. No. LX. Sig. One pill after dinner. Where there is too great a redundancy of the mucous membrane of the pouch so that, in the act of defecation, its folds obstruct the passage, an operative procedure may have to be resorted to.^ Atony of the whole intestinal tract may result from atony of the rectum.^ 1 Kelsey, " The Surgical Treatment of Constipation," New York Medical Journal, May 16, 1896. 2 " Atony of the Rectal Pouch," etc., by William Bodenhammer, M.D., New York Medical Record, April 6, 1889. Van Buren, Lectures on the Dis- eases of the Rectum, " Atony of the Rectum," 1882. Mathews, loc. cit., " Impaction of Ffeces." Kelsey, The Diseases of the Rectum. Curling, On the Diseases of the Rectum. Trousseau, A., Gazette Me'dicale (de Paris), Tome VIII., No. 36, 1840. CHAPTER XXIII treatment of atony of the intestine dependent upon morbid processes 1. Constipation dependent upon Chronic Intestinal Catarrh Constipation is frequently due to a catarrh of the large bowel. In fact, it is laid down as one of the characteristic features of chronic catarrh of this section of the intestinal tract that the patients are constipated the major part of the time. This constipation alternates with diarrhoea, in this wise : the patient may go three or four days without an evacuation, and then a diarrhoea will supervene which may last a whole day or cease with two or three very thin discharges following each other in rapid succession. An examination of these discharges will show' undigested matter in considerable quantity, and will also disclose to us (by the odor) that fermentation or putrefactive pro- cesses have therein developed. The treatment of this form of constipation is in reality the treatment of the intestinal catarrh. I. Of the utmost importance is the regulation of the diet. All vegetables and all raw fruits are strictly pro- hibited ; all meats, whether fish or flesh, are banished from the list of edibles. The diet list is made up of the following articles : rice, barley, farina, fine ground hominy, 317 318 CONSTIPATION IN ADULTS sago, cornmeal, oatmeal. Occasionally, vermicelli or grated noodles ^ are well borne and can be permitted. Cocoa, milk, black tea. Chocolate can be eaten. A little syrup (maple or cane) or honey, as an addition to the farinaceous articles, may generally be permitted. All food must be boiled or baked (with the addition of a minimum quantity of sweet butter). Anything fried is absolutely hurtful, and must therefore be strictly forbidden. No alcoholic liquor of any kind. Later on, as the case progresses favorably, a soft-boiled, or a hard-boiled, cold, (so-called railroad) egg can be per- mitted. Meats and fish are not allowed until the patient has fully recovered. II. Massage. — At the outset, the mild introductory effleurage and manipulations 3 and 4 of Group C, gently made. Later on these are executed more vigorously, and the various other manipulations as the case progresses. III. Hydrotherapeutic Measures. — First of all the large clyster to effect a daily evacuation, and thus prevent accu- mulation of faecal matter and subsequent irritation of the intestinal mucous membrane. The injection has also a curative effect upon the irri- tated intestinal mucous membrane, and therefore can be made, if desired, of decoctions of aromatic herbs, as chamo- mile or peppermint — the latter has a remarkably soothing and quieting effect upon the bowels. Or strong infusions of these herbs may be added to the cold water. The cold moist-abdominal bandage applied as described. IV. Medication. — I have generally found that these 1 See formulary. TREATMENT OF ATONY OF THE INTESTINE 319 measures, of which I consider the dietary regulations as of the first and foremost importance, succeed in relieving the ailment without any medication. Sometimes I have thought it advisable to prescribe small doses of phosphate of soda, where there seemed to be an insufficient quantity of lubricating mucus secreted. When too much was secreted, I have found the decoction of cortex simaruba of the greatest value in modifying it, and bringing it within normal limits. There is, for this purpose, nothing superior to it in the pharmacopoeia. II. Atony from Morbid Processes Elsewhere 1. Neurasthenia {Nervous Exhaustion). — As a result of the physical depression characteristic of neurasthenia, we have, not infrequently, constipation, alone or com- bined with other dyspeptic phenomena, as one of thfe manifestations. In the diagnosis of neurasthenia, this very important point must be borne in mind, that constipation or indiges- tion may give rise to symptoms much like those found in neurasthenia, and may thus lead to error. The treatment here must be essentially that of the neurasthenia. With its relief or improvement the con- stipation will also be improved, or disappear. We may send our patient to the mountains. We may advise a sea voyage.^ But best of all ^ we will institute a hydropathic treat- ment which is superior to other methods of treatment in the permanency of its benefits. ^ Osier, Practice of Medicine, 1892. Lowenfeld, Pathologie u. Therapie d. Neurasthenie u. Hysterie, 1893. 320 CONSTIPATION IN ADULTS The measures particularly indicated here are : The cold moist-rubbing. The cold tub-bath. If treatment can be had in a hydropathic institute : The hot-ail' bath, of short duration, followed by The cold rain-bath, or by The cold fan-douche, or the alternately hot and cold fan- douche.^ It will be best, especially where the depression is very marked, to begin with the cold moist-rubbing, having the temperature of the water in which the sheet is soaked at 90° F. to 85° F., and gradually reduce it, in the course of the period in which the patients are under treat- ment, to 75° F., to 70° F. Then we may substitute for it, for a time, the cold tub-bath or, where the patient can avail himself of the advantages of a hydropathic institution, the hot-air bath and douches as described. Sea bathing is beneficial. General massag'e, including the abdomen, may be re- sorted to. We may employ electricity, galvanic or faradic. Gal- vanization of the head is apparently of much benefit. In very apathetic individuals general faradization will be useful. We will carefully regulate the diet. It should consist mainly of milk, meat, and eggs. Milk is a very important factor; one and one-half to two quarts per day should be taken. All alimentary articles, tending to produce flatu- lence, which is doubly distressing and doubly irritating to the neurasthenic and tends to make the constipation more obstinate, must be avoided. 1 See chapter on » Hydrotherapy." TREATMENT OF ATONY OF THE INTESTINE 321 As to the special feature that concerns us here, the constipation, we will direct in the diet of the patient cer- tain articles which favor peristalsis: buttermilk, two or three glasses per day (replacing the same quantity of other milk). This I have found especially beneficial. Then the fruits: baked apples, apples baked in syrup, prunes, etc., as described. In the course of the hydropathic treatment we will have the fan-douche directed particularly to the abdomen, to the tract of the large bowel. We will resort to large injections of water, as already described. We can employ the electrical current as already de- scribed above. It may become necessary in the course of treatment, either for the purpose of securing a more thorough empty- ing of the bowels, or for the general revulsive effect upon the abdominal organs, to resort to a purgative. A com- pound cathartic pill, U. S. P., one of the various aloetic pills, or, if the bitter taste be not objectionable, the mixture described in the formulary as a " tonic laxative," one teaspoonful every three or four hours until the desired effect is obtained, can be directed. In the neurasthenia of sexual origin, with persistent irrita- bility of the sexual organs, we will resort, in the male, in addi- tion to the measures already described, to the psychrophore (Kiihlsonde, cooling sound), described in detail further on. In women, I have derived marked benefit from the wet pack as employed by me in the treatment of summer complaint. ^ A sheet is wrung thoroughly out of cold water ; the patient, * "Sutniuer Complaint," a clinical contribution, etc., New York Medical Journal, 1892. 322 CONSTIPATION IN ADULTS naked, is wrapped tlaerein, and then covered with blankets. As soon as the sheet is warm, it is removed, and a fresh one applied. This is continued for two hours, during which time from four to six sheets are used, — more in summer, less in winter. In the cold months, the room must be thoroughly warmed. I have also, at times, applied the wet sheet folded so as to reach from about the upper border of the liver to the knees.^ The administration of some tonic, as strychnine with bark, strychnine with acid, strychnine with hypophosphites, according to the particular indications presented, will add efficacy to our other measures. 2. Debility after Protracted Maladies. — The general debility, consequent upon long febrile processes, as typhoid fever, remittent or intermittent fever, may involve, to a marked degree, the intestinal tract ; and constipation, some- times very obstinate, results. It is, however, of but little importance otherwise. As the general system gains in vigor, the bowels become stronger and more active. To secure their action mean- while, we can resort to electricity, which is especially indicated for the permanency of its benefits; to the large clyster ; to the injection of oil;^ to the glycerine injection or suppository; occasionally to an aloetic pill; to a dose of the compound rhubarb powder or other mild and stimu- lating cathartic. I have obtained very good results with the preparations of malt regularly administered, both as to tonic and laxative effects. 3. Disease of the Heart. — In the course of organic disease of the heart, when the normal functioning thereof becomes 1 For further details, see Beard, Nervous Exhaustion, 1888. Lowenfeld, , .. 2 See chapter " Oil Injections. TREATMENT OF ATONY OF THE INTESTINE 323 impaired, a state of congestion of the whole intestinal tract may supervene, and constipation result. ^ This constipation is not really due to atony, but rather to change in the intestinal tissues, and to insufficient oxygenation of the blood. For the relief of the constipation we will make use, for reasons known to all, of the hydragogue cathartics ; of the compound powder of jalap ; of the compound infusion of senna ; of epsom salts, etc. ; or we may resort to the active mineral waters, as Hunyadi Jdnos, Friedrichshall, or Pullna. At the same time we will attend to the heart, which will also be greatly benefited by our hydragogue cathartics properly and discreetly used. 1 Walshe, Walter Hayle, Diseases of the Heart, 1862. Striimpel, Text- book of Medicine. CHAPTER XXIV TREATMENT OF SPASTIC CONSTIPATION; ENTEROSPASM It is the general experience that the measures, so fruit- ful of good in atonic constipation, are of no avail when the retention of the faeces is due to a spasmodic contrac- tion of the intestinal muscle. The indications for treatment here are twofold: First. The relief of the spasm. Second. The removal of the cause that provokes it. I. Belladonna. — For the relief of the spasmodic state, belladonna is the remedy par excellence. Trousseau^ ex- tols it highly, and it is, undoubtedly, in the constipation dependent upon enterospasm, that it achieves its greatest successes.''^ It may be given in the form of the tincture, guttse 5-10 every four hours (about three or four doses per day). Rosenheim gives gtt. x per day. It may be given as extract in pills one-sixth to one-fourth of a grain, three or four times daily ^ Extract. Belladonna. (English) grs. ii Extract. Gentian. Extract. Taraxac. aa grs. iv-vi M. ft. Mass. et divid. in pillul. sequal. No. VIII-XII. 1 Trousseau, Clinical Lectures. Translated, Philadelphia, 1873. 2 Phillips, Materia Medica and Therapeutics. H. C. Wood, loc. cit. 8 I have found this to be a sufficient dose when the English extract is used. 324 TREATMENT OF SPASTIC CONSTIPATION 325 Trousseau ^ prescribed the following pill : ^ Pulv. Folia. Belladonna. Extract. Belladonna. aa 0.01 = (gr. |). M. make one pill. The directions are: " One of the pills is taken, by pref- erence, fasting in the morning, on an empty stomach. The number of pills may be increased from one daily to two daily within the first five or six days; they ought seldom to exceed four or five in the course of the twenty- four hours. Whatsoever number of pills are taken, they ought always to be taken at one time." ^ 1 have myself made use of this formula, ordering the pills to be taken in accordance with the directions above given, and have always been very well satisfied with the results obtained therefrom. It can be ordered in the form of a suppository with Oleum Theobromce : 5 Extract. Belladonna. (English) gr. ^— ^ Ole. Theobroma. 3 i M. ft. Suppository No. I. One to be introduced into the rectum night and morning. For suppositories it is perhaps better to prescribe the alkaloid atropia; for greater safety, and perhaps even greater effectiveness, a little morphia may be added : 5 Atropia. Sulphat. gr. g^. Morphia. Sulphat. gr. ^ Ole. Theobroma. 3 ss M. ft. Suppository No. I. Sig. Introduce one at bedtime. ^ Loc. cit. 2 Trousseau, Clinical Lectures, Philadelphia Edition, Vol. II., p. 493, 326 CONSTIPATION IN ADULTS I have found it advantageous to combine with the in- ternal administration of belladonna, and more especially when it is directed in the form of suppositories, the exter- nal application thereof. I prescribe for this purpose the unguentum belladonnse, and direct that a piece about the size of a pea or white bean be rubbed in over a section of the large gut morning and evening, varying the locality each application. In this way a much quicker effect is obtained than with the internal administration alone. Hyosciamus, belonging with belladonna to the same group of remedies, is also said to be useful in relieving enterospasm . It may be given in the form of tincture, gtt. V to XV every three or four hours (three or four times daily), or as extract, in pill form, from one-half to one or two grains every three or four hours. It may be combined with belladonna, a smaller dose of each of these remedies being then given. It has been recommended by some ^ to combine a mild laxative with the antispasmodic. When this is done, but the mildest of purgatives should be used, and in very small doses : extract of taraxacum, extract of rhubarb, extract of cascara sagrada, extract of rhamnus frangula, extract of butternut {Juglans cinerea). Occasionally very small doses of the compound extract of colocynth, one- twenty-fifth to one-thirtieth of a grain, may be given with the belladonna to great advantage. The minute doses of the purgative correct the abnormal peristalsis, and thus, with the antispasmodic, relieve the enterospasm and the tendencies thereto. 1 H. C. Wood, loc. cit. TREATMENT OF SPASTIC CONSTIPATION 327 Valerian, Assafoetida. — These remedies will be of ad- vantage in pronounced neurasthenic and hysterical cases. The valerian can be given as the simple tincture of valerian or as the ethereal tincture, in doses of fifteen to thirty drops every three hours. I prefer to give it in the form of valerianate of zinc. Various elegant elixirs of valerianate of zinc are made, and I have used them with great benefit in neurasthenic cases, the remedy combining tonic and antispasmodic properties. The assafoetida is best in the distinctly hysterical cases. It must then be given in large doses, ten grains four times a day.^ It is best given in pill form. Oil. — Fleiner recommends as sole treatment the injec- tion of oil. For details see the special chapter further on. If there be much pain with the spasm, we will reheve the same by the administration of opium in some form, alone or in combination with the belladonna. I generally prefer the sup- pository of atropia and morphia (the latter, of course, in larger doses than in the formula given above, from one-fourth to one- third and even one-half a grain per suppository), as giving better results and with less disturbance to the general economy than any other mode of administration. If opium be for any reason contraindicated, we may give camphor with our belladonna, or we may resort to sulphuric ether. Hoffmann's anodyne is a convenient form of adminis- tering the latter. Where there has been a long retention of faeces, I have occa- sionally found a pill of morphia and belladonna, with minimal doses of colocynth (compound extract) or of podophyllin, one- thirtieth of a grain, to afford rapid relief. It may be necessary to provoke a rapid evacuation of the ^ Dr. Louis Stromeyer, Erfahrungen iiber Lokal-Neurosen, Hannover, 1873. 328 CONSTIPATION IN ADULTS bowels. This we will effect by means of injections of very warm water (90° F. to 100° F.), or very warm infusions of some aromatic herb, as chamomile. I prefer the addition of milk of assafoetida,i prepared as already described above, S ii-iii to the whole quantity of water. It has always acted exceedingly well for me. Besides the rapid emptying of the bowels, an abundant discharge of flatus, which is frequently the cause of the pain, is provoked by the assafoetida, and the spasm is allayed. Injections of cold water are decidedly objectionable and aggravate both the pain and the spasm. External applications, as hot poultices, hot-water bags, and such like, I consider of but little value in the condition under consideration. Electricity. — The galvanic current may be of great value here, more particularly in that form of enterospasm which is dissociated altogether from pain. II. The spasmodic contraction overcome, and the func- tion of the bowel re-established, we will turn our attention to the etiological factors and endeavor to banish them. If a catarrhal condition of the large bowel exist, as shown by the evidence derived from the faeces, and catarrh is a not infrequent cause of spasm, we will seek to cure the same. If a neurasthenia be responsible for the condition, we will treat the same upon the lines already indicated, resorting at first only to the gentlest measures of the various methods of mechanical treatment. Occasionally, the enterospasm may be due to the exag- gerated use of sharp condiments, as pepper, — especially the red, — ginger, etc., or combinations of these in the 1 The milk has seemed to me to act much better than the tincture. TREATMENT OF SPASTIC CONSTIPATION 329 form of the various sauces. A return to a plain diet will be the first requisite for a permanent cure. Spasmodic Stricture of the Rectum. — All lesions being excluded, the line of treatment just advocated for entero- spasm is well adapted to the treatment of spasmodic stricture of the rectum. I believe, however, that here assafoetida will do more good than any other of the group of antispasmodics ; for the reason that these cases, with rare exceptions, are found in persons with hysterical tendencies, or, at least, with an inclination to disturbance of the nervous equilibrium. The wonderful success of Stromeyer^ with this remedy should certainly encourage "us to give it a thorough and conscientious trial in those rather mysterious troubles of the rectum where nothing can be found locally to account for the great suffering. I can myself bear witness to the remarkable effects of very large doses of this drug. The assafoetida should be administered in massive doses, ten to fifteen grains, four times a day. With it we can give some tonic according to the indications that the patient presents. From its well-known beneficial action in spasmodic affections elsewhere,^ the application of the galvanic cur- rent seems certainly indicated. The mode of application might be in this wise : A medium-sized electrode, cathode over the region of the solar plexus, and another and some- what smaller electrode, anode over the sigmoid flexure at its lowest reachable point. Duration of application, about three minutes. The cathode is then placed over the 1 Erfahrungeu iiber Local-neuroseii, Hannover, 1873. Erb, Elektrotherapie, loc. cit. 330 CONSTIPATION IN ADULTS caecum and the anode about a hand's breadth in ad- vance upward; the two poles are thus carried gradually over the whole large bowel down to the farthest point, possible, of the sigmoid flexure; or the cathode may remain stabile and the anode alone be labile. Then the cathode is replaced over the caBcum, the anode retained at the S. flexure, and the continuous current allowed to flow through. Duration, four minutes. The internal method (unipolar or bipolar) may be tried. Spasm of the sphincter without local lesion (spasmodic constriction of the anus). Spasm of the sphincter without local lesion is chiefly an affection of hysterical or neurasthenic persons, and in its treatment this must be taken into consideration. For the hysterical, large doses of assafoetida will be prescribed, and for the neurasthenics, those remedies that give tone and vigor to the system according to the indica- tions presented, as given more in detail in the next chapter. For the local manifestation, the topical application of belladonna, in the form of ointment, to the sphincter, with suppositories of belladonna or of atropia for the rectum, or belladonna administered internally, is here also in place. Hyosciamus and cannabis indica may take the place of belladonna ; but they are, as a rule, not as effective. They may be given in combination with belladonna. A cathartic will sometimes act very nicely and break up the spasm. ^ When these measures fail to bring rehef, we will have recourse to a mechanical measure which is always effectual, namely, forcible dilatation.^ 1 Kelsey, loc. cit. . 2 " De la Dilatation Forcee dans le Traitement de la Constipation Opi- TREATMENT OF SPASTIC CONSTIPATION 331 Forcible dilatation may be made with the hands alone, or with the aid of instruments. When made with the hands, the modus ojjerandi is this: "Both thumbs are introduced into the rectum [first one, then the other], back to back, well beyond the sphincter ; then, taking a purchase from the buttocks with the outspread fingers, carry the thumbs gently and slowly, but forcibly, apart until their palmar surfaces are arrested by the ischial tuberosity." ^ When the sphincter muscle has become large and hard from this unnatural exercise, — the strong and long-con- tinued contractions,; — we will, after having stretched it in one direction, turn the thumbs and stretch the sphincter in the other direction. We will then, with some press- ure, massage the sphincter all around, making petrissage between the thumb and forefinger, and again pull the anus apart with four fingers, two on each side. Under this treatment the sphincter will give way completely, and feel like a well-beaten steak, or like putty. ^ If it be pre- ferred to do this instrumentally, one of the various anal specula, where the separation and holding apart is accom- plished by means of screw power, may be used therefor. Van Buren, as do most of the modern rectal surgeons, preferred the manual method. As the procedure is a very painful one, it is best done with the patient under the influence of an anaesthetic (ether, chloroform). This is more particularly so in weak and nervous patients (usually women), or when the pro- niatre," Championnere, L., Journal de Medecineet de Chirurgie Pratique, 1877. Gazette Medicale d. Hopitaux, 1877. ^ Van Buren, loc. cit. Allinghani, Diseases of the Rectum. * 332 CONSTIPATION IN ADULTS cedure is necessarily a more prolonged one, as when the sphincter muscle is unduly thickened. In strong and vigorous persons, when dilatation alone is necessary, an£Esthesia may be dispensed with. Where no general anaesthetic is administered, a local anaesthesia by means of cocaine, ten to fifteen per cent solution, should be produced. The patient is placed in the knee-elbow position, and the buttocks being well drawn apart, he is asked to press down ; the anus and sphincter being thus unrolled, they are painted thoroughly with the solution and repainted ; then a little wad of cotton-wool, moist with the solution, is placed in the ring of the sphincter, and the anus permitted to retract and the but- tocks to fall together. After a few minutes the wad is removed, and replaced by a fresh one. In about ten minutes a decided anaesthesia of the parts is effected. If the spasm be due to reflex irritation from the urethra or the neck of the bladder (and this is a point that should always be inquired into in spasmodic troubles of the anus and rectum), we will have to attend to these before we can expect permanent relief. In the meanwhile we will be able to allay the spasm with the suppositories of atro- pia or belladonna (alone, or combined with morphia ac- cording to formulas above given). I have in this way succeeded in affording rapid relief from spasm of the sphincter ani coming on in the course of a severe gonorrhoea. CHAPTER XXV TREATMENT OF CONSTIPATION DUE TO IRRITABLE RECTUM Under the terms of Irritable Rectum, Hysterical Rec- tum, Nervous Rectum, has been described a derangement of the lowermost segment of the large bowel, character- ized seemingly by a hyper-irritability of the rectal mucous membrane, or of sections thereof (the hyper-irritability is frequently confined within circumscribed patches), or of the nervous filaments distributed thereto, and an absence of all apparent local lesion that might account therefor. We must exclude from this category those cases in which well-defined disease of the urinary tract is found, as this may, as has already been stated with regard to spasm of the sphincter, produce other disturbed conditions of the rectum. That the nervous system is mainly at fault, is demon- strated by the fact that the trouble is met with only in persons with a well-marked tendency to hysteria or already hysterical, and in persons in whom the nervous equilib- rium has been disturbed by exhaustion of the nervous and general systems. This derangement presents itself to us with diverse phenomena. Sometimes it is a sense of uneasiness in the rectum, a sort of nagging feeling, as it were, that makes the person afflicted aware that he has such an organ and 333 334 CONSTIPATION IN ADULTS keeps his mind constantly upon it, until he can think of nothing else and becomes morose and melancholy. At other times it is a marked pain on defecation, so great as to almost fill the patient with terror at the thought of an evacuation, and cause him to go as long as possible with- out one. Or the pain may come on at regular or irregu- lar intervals, even with a marked periodicity of almost malarial correctness. At other times it is characterized by a general collapse, that comes on with the stool, though there may be no pain at the time ; nothing but an inde- scribable sickening sensation, as one patient expressed himself. A cold sweat breaks out upon the person af- fected, the hands become cold, the pulse feeble, there is a sense of nausea and a feeling as if one's last hour had tolled. In the treatment of this most annoying, and to the patient sometimes terrible, derangement much tact will be required and careful study of the individual case. In the hysterical, large doses of assafoetida are cer- tainly indicated, and promise success. What this large dose is has been already stated. If, for any reason, assa- foetida cannot be taken, the valerianate of zinc in pill,^ or in the form of elixir (to which also an addition of the tincture of valerian can be made), will prove of decided benefit. In cases of nervous exhaustion (neurasthenia), of gen- eral debility, it will be our first care to build up our patient, to invigorate him. Abstention from mental IB Zinc. Valerian. grs. ii Extract. Valerian. grs. ii Extract. Gentian. q. s M. ft. Mass. et ft. pillul. I. Sig. One pill three times a day. CONSTIPATION DUE TO IRRITABLE RECTUM 335 work; abstention from the usual pursuits, if possible; moderate exercise in the open air ; diversion of the mind (Zerstremmg), — will be advised. The diet will be care- fully regulated, and such tonic medication as may appear indicated, prescribed. Iron (for the anasmic), in the form of Blaud's pill (one pill three times a day, and increased every fourth day by one, until three pills are taken three times daily ^), or as the syrup of the iodide of iron and manganese. A good preparation of a similar character is Gude's pepto-man- ganate of iron (pepto-mangan). We can also give the iron in the form of a valerianate. Arsenic. Phosphoric acid, with bark (especially good in cases of nervous prostration). The hypophosphites with strychnine. If the digestion is impaired, we will be greatly aided in our restorative efforts by the administration of hydrochloric acid with some bitter infusion, as of gentian or cascarilla, or with nux vomica or strychnine. Several of these remedies may be combined in one pre- scription. GoodelP prescribed a pill as follows {Pillul. Surribul. Comp.) : ^ Extract. Sumbuli gr. i Assafoetida. grs. ii Ferri Sulphat. gr. i Acid. Arsenics. gr. M. make one pill. Sig. One pill three times daily. The quantity of assafoetida is rather too small to be of much benefit. ^ Goodell, loc. cit, ^ Loc. cit. 336 CONSTIPATION IN ADULTS Or we may prescribe a pill like this : R Zinc. Valerianat. grs. ii Ferri Valerianat, gr. i Strychnina. Sulphat. gr, ^ Extr. Cannab, Indie. gr. ^ Extr. Gentian. q. s M. make one pill. (If preferred, the mass can be put into a capsule.) Sig. One pill three times a day. 5 Zinc. Valerianat. Ferri Valerianat. Quinia. Valerianat. aa gr. i M. ft. Mass. et ft. pillul. No. I. Sig. One pill three or four times daily. Goodell also prescribed the following : 5 Aur. Chlorat. Natron. gr. |^ SAuri et Sodii Chloridum ) Chloride of Gold and Soda ) Zinc. Valerian. grs. ii Extract. Hyosciam. gr. i M. ft. Mass. et ft. pillul. No. I. Sig. One pill three times a day. In addition, we may resort to the various hydropathic procedures already indicated above. I have seen very good results in building up a broken-down nervous system, from a properly arranged hot-air bath of very short dura- tion, followed by the cold rain-bath or the Scotch douche to the vertebral column and body generally. For the sudden paroxysms of pain, nothing is so effec- tive, according to Goodell, as antipyrin in doses of five to ten grains, or hyoscin, grain ^2^1 administered every two hours until the suffering is relieved. A Spanish-fly plaster CONSTIPATION DUE TO IRRITABLE RECTUM 337 of the size of a quarter or half dollar, applied over the coccyx, has done me good service. Local applications of ointments or anodyne injections are of no benefit; rather harmful than aught else. Of the greatest benefit, how- ever, both in a curative sense and for the relief of the imme- diate suffering (better even than the remedies above named for this last purpose) is the local applica- tion of cold. It may be applied by means of the Atzperger appa- ratus. This apparatus consists of a short metal cylinder to which are attached an affluent and an effluent pipe. To the cylinder is fixed a hollow, pear- shaped, metal stem, without any openings, which, well oiled, is carried into the rectum. The arrangement atzperger Apparatus. of the apparatus is as shown in the cut. The water flows in from an elevated vessel, and flows out through the effluent pipe into a vessel on the floor.^ By the constant inflow of cold water and the outflow of the warmed water, the parts are kept refrigerated. Or it may be accomplished by means of Winternitz's device. This consists of a hollow metal staff, six to twelve centimetres in length, ending in an olive point which, as well as the taper- ing neck, is provided with numerous small orifices. This staff, ^ Winternitz, loc. cit. 338 CONSTIPATION IN ADULTS at Its lower extremity, divides into two branches like the double- current catheter. To one of these branches is attached an alHuent pipe, carrying water from a vessel placed at an eleva- tion, and to the other branch, an effluent pipe, which carries off the warmed water to a vessel on the floor. Just above the point of union of the two branches, a metal disc with a grooved border is fixed. The staff is covered with a rub- ber bag (ice-bag) or a thin fish bladder, and its open end attached firmly to the grooved border of the disc. The bladder or bag is wound snugly around the staff, well oiled and introduced into the rectum. The water being allowed to flow in through the affluent tube, whilst the effluent one is shut off (by means of clasp or cord), the bladder is filled and becomes distended. This dis- tention can be carried to any required extent, and we may thus have compression with refrigeration. ^ If the sensitiveness of the parts be too great to tolerate the apparatus (which is not often the case), we can first anaesthetize them in a measure by the application of a ten to fifteen per cent solution of cocame, by means of the applicator or by the aid of small wads of cotton intro- duced gently into the rectum. Or we can resort to the application of carbonic acid (COo), which the investigations of Brown-Sequard have shown to have a marked anjBs- thetic effect upon the tissues.^ ^ Winternitz, loc. cit. 2 Comptes Rendus des Seances et Memoirs de la Societe de Biologie, 1882. Pr ogres Medical, 1882. WiNTERNlTZ's DEVICE. CONSTIPATION DUE TO IRRITABLE RECTUM 339 We can do this readily with the contrivance devised for this purpose by Dr. A. Rose of this city. He describes it as follows : " It consists of a bottle holding a pint or more with a wide mouth and a rubber stopper, the latter perforated so as to admit a glass tube which, at the external end, is connected with a rubber tube to which is attached a nozzle to be in- troduced into the rectum." The bottle is filled with water about one-third full, not quite up to the in- ner extremity of the glass tube. Into the water six drachms of bicarbonate of sodium are put, and when every- thing is ready for the application, one-half ounce of tartaric acid, in large crystals, is added, and the vessel quickly closed. ^ The cooling apparatus can be left in the rectum for an hour or two, and the application can be repeated on the same or on the following day. The injection of cold ivater into the rectum sometimes suffices. Mathews^ relates a rather remarkable case of this character which, after innumerable measures and things had been tried in vain, was promptly cured by an injection of cold water.^ 1 New York Medical Journal, March 9, 1895, " Therapeutic Effects of Carbonic Acid." Mathews, loc. cit. ^ See on irritable rectum, Goodell, Mathews, Kelsey, loc. cit. CHAPTER XXVI TREATMENT OF CONSTIPATION DEPENDENT UPON GENITO- URINARY TROUBLES This form of constipation has already been alluded to elsewhere. It remains only to be said that chronic affec- tions of the genito-urinary tract, and more particularly in the male, may be the exciting cause of a chronic form of constipation.^ They do this, sometimes, by provoking a spasm of the sphincter ani, as has already been said ; at other times an irritable condition of the rectum is devel- oped, and then again, as in spermatorrhoea, we cannot account for it except on the grounds that the nerve fila- ments of the lower segment of the rectum and the nerve centre in the lumbar section of the cord are obtunded, or that the irritability of the w^hole nervous system is lowered. As will suggest itself at once, the etiological factor must be promptly attended to, to permanently cure the constipation. Here, also, the Atzperger cooling apparatus or the device of Winternitz will be of great service. Winternitz ^ regards it as highly efficacious in spermator- rhoea, as well as in cases where a chronic inflammatory condition persists. Its value in cases of seminal weakness has but lately received additional confirmation.^ 1 Peyer, loc. cit. 2 Winternitz, loc. cit. 3 New York Medical Record, April 13, « A New Treatment of Seminal Weakness," etc., by Alfred Wiener. 340 CONSTIPATION FROM GENITO-URINARY DISEASES 341 The introduction of the cold sound will be resorted to where indicated. We may, in place of the sound, have recourse to the psychrophor, a cooling apparatus for the urethra. PSTCHBOPHOB. It needs no long explanation. It is a closed double-current catheter, dividing, as that instrument does, at its lower extremity into branches. To one of these is connected an affluent, and to the other an effluent pipe. The arrangements for the inflow of water are the same as for the other cooling devices already described. It is introduced into the urethra, and allowed to remain for the length of time that may seem proper. In cases of chronic inflammation it will be introduced so that the point passes just beyond this locality. In cases of spermatorrhoea the point should pass the pars prostatica of the urethra, reaching up to the sphincter of the bladder. The instrument should be used methodically, but not too frequently. The temperature of the water should not be too low; from 57° F. to 54° F. generally suffices. It should not be lower than 50° F. Duration of application, about eight minutes ; at most, twelve minutes.^ I have obtained excellent results in cases of sperma- ^ Winternitz, loc. cit. 342 CONSTIPATION IN ADULTS torrhoea with the use of the cold pack, from the umbilicus to the knees, as described in Chapter XVIII. I direct that the patient be put into the cold pack every morning for two hours. At night, before retu:ing, a warm bath is taken to relax the tonus of the small ring muscles about the vesiculae seminal es.^ Where the psychrophor is used, the other cooling devices mentioned above are, of course, dispensed with. In the meanwhile, the bowels will be kept soluble by means of cold-water injections, of mild and tonic laxatives, as the tonic laxative of the formulary, or by means of laxative mineral waters, as Hunyadi Janos, Pullna, Carls- bad, Saratoga. If, after the ailments of the genito-urinary tract have been cured, there remains a weakness, a torpidity of the bowels, we will treat this in the manner already set forth for atonic constipation. 1 Illoway, " Hydrotherapeutics," Cincinnati Lancet and Observer, 1877, and other papers on the Summer Diarrhoea of Children. CHAPTER XXVII FISSURE OF THE ANUS Fissure of the anus may be the cause of the spasm of the sphincter ani or even of the rectum. The treatment therefor will be found in detail in the various works on the " Diseases of the Rectum." As to forcible dilatation, which with many is a favorite mode of treatment, this has been already described in full. Fissure of the anus may, as has been said, result from con- stipation. It occurs in those cases where the faeces become very much inspissated and indurated and aggregated together into large masses which then require much force and much violent dilatation of the sphincter for their expulsion. Under these conditions it will be found that despite the best and most thorough treatment there will be a tendency to a return of the fissure. To obtain a permanent cure, it will be necessary to treat the atony of the intestine with the various mechanical measures. We will employ massage ; this will break up the large lumps and will stimulate the secretion of mucus, and thus effect a better lubrication. We will avail ourselves of the benefits to be derived from the clyster, and direct the use, daily, before going to the closet, of a small injection, one half to one pint, of cold water to still further soften the faecal masses. These injections can be continued for a time (two or three weeks) even after the fissure is entirely healed. In this way abrasions of the delicate mucous membrane lining the sphincter ani will be inhibited. I have succeeded in healing, in this wise, fissures that have recurred again and again, without resort to any operative procedure or local treat- 343 344 CONSTIPATION IN ADULTS ment other than the light application of the solid stick of argeutiun iiitricum. The further precautions to be taken, are these : In all cases of fissure or abrasion the use of paper as a cleans- ing material after defecation is strictly and absolutely prohibited. Cotton-wool, absorbent cotton, is prescribed for this purpose. As long as the fissure is open, the parts are to be cleansed with a mild solution of boracic acid (two tablespoonfuls of the satu- rated solution to a glass of water). After it is healed, I direct that there be applied to the sphincter (after it has been cleansed with a wad of dry cotton) the following solution: Acid. Tannic. 3 i Glycerin. S ii M. ft. Mixt. Sig. Use as directed. The patient presses down again (unrolls the sphincter) and applies the above solution on a wad of cotton, holding it against the sphincter for a few minutes. This is continued for two or three weeks, and is for the pur- pose of hardening the parts and at the same time closing up and healing at once any abrasion or fissure that may have been then produced. The prohibition against the use of paper, even toilet paper, must be carefully observed for a long time, at least six months. CHAPTER XXVIII HAEMORRHOIDS It is not the scope of this work to go into the details of the surgical treatment of piles, of their treatment by the injection method (injection of carbolic acid or of admixtures thereof into the body of the tumor), or of their treatment with acids. These can be found in the excellent works of Kelsey, Mathews, Bodenhammer, Ball, and Van Buren. This chapter here is only intended to direct attention to certain other measures, not so well known to the profession in general, that are available for the treatment of haemorrhoids, when the more radical methods are refused or cannot be resorted to for one rea- son or other. That these measures, primarily intended to relieve the constipation, the congestion, are not infre- quently very effective in causing the dispersion of the tumors has been shown by much observation, and has been verified to me in my own clinical experience. A number of ladies in my clientele were invariably, after every confinement, troubled with hasmorrhoids which caused both constipation and suffering. By prompt treatment after the method described here, without re- course to any forcible measures, the haemorrhoids dis- appeared not to return again till after the next labor. In two cases, where pregnancy did not recur, there was no recurrence of the piles. These measures are : 345 346 CONSTIPATION IN ADULTS A i^roper regulation of the diet. Exercise. Massage. Hydropathic treatment. I. A Properly Regulated Diet. — WUi has been said above, under this head, with reference to the treatment of atonic constipation, applies here as well. All things that tend to promote the activity of the intestines, to invigorate their various structures, must contribute to the cure of hemorrhoids. Only this need be set forth more particularly that the use of spices, as black pepper, ginger, cinnamon, must he very much restricted; that highly sea- soned foods and condiments are to be altogether avoided, and that alcoholic liquors, especially red wines and bran- dies, must be absolutely prohibited as directly and posi- tively injurious. II. Exercise. — All that has been said before holds good here. The supposition that horseback riding is productive of piles is fallacious.^ III. Massage. (a) Abdominal massage as already described. The introductory effleurage is an important part of the treatment, and is made, as already stated, from the periphery to the centre, i.e. from the symphysis of the pubis to the navel. Beating of the sacrum is especially indicated and, according to Reibmayer, of much efficacy.^ If not inflamed, the hsemorrhoidal tumors themselves 1 In addition to the authorities quoted, see " Equitation and Cycling," etc., by Bodenhammer, New York Medical Journal, November 2, 1895. - Loc. cit. HAEMORRHOIDS 347 can be massaged (effleurage and light petrissage). To subject inflamed tumors to such treatment is not alone barbarous, but very dangerous.^ Massage of the hsemorrhoids is made within the rectum. The patient is placed on his side, or in the lithotomy position, and the tip of the finger, well oiled, first introduced, and then gradually and slowly the whole finger pushed up as far as required. For the effleurage, light strokes, as long as possible, are made. For petrissage, the tumor is slightly compressed between the tip of the finger and the rectal wall.^ (&) Gymnastics. Active Exercise, Figs. 8, 9, 10. Resistance Exercise, Figs. 13, 14, 15, 18 a and 19. Passive Exercise, Figs. 21, 23, 24. IV. Hydrotherapy. {a) The injection of cold water into the rectum and bowels, both for its evacuating as well as its tonic effects upon the muscles of the rectum and the walls of the ves- sels. Van Buren ^ believed that a better way is to obtain these two different effects separately, by two distinct procedures ; namely first inject a large quantity of water, not cold, — even tepid, if there be much accumulation and induration of faeces, — to soften the faecal matter and effect its discharge ; then follow with a small, cold injec- tion, " about a tumblerful, and as cold as can be comfort- ably borne," for its constringing action and tonifying effect upon the tissues of the part involved. This last is allowed to become absorbed. I prefer the ordinary cold injection as already described 1 Reibmayer, loc. cit. 2 Reibmayer, Die Unterleibs-Massage. ^ Loc. cit. 348 CONSTIPATION IN ADULTS here ; I think the effect of even lukewarm water is preju- dicial. The injection can be given once daily, — best in the morning before rising, or at bedtime before retiring, — or once every other day, according as the stool keeps soft or not. This is a very effective measure. (6) The cold douche to the lower part of the trunk, both anteriorly and posteriorly. The Scotch douche is of great benefit, and can be applied to the perineum also. (c) The hasmorrhoidal bandage: This is a sort of T bandage. It consists of two parts : a circular part to be applied as a girdle around the abdomen, and a vertical portion, attached to the middle of the girdle and at right angles to it, posteriorly, which is applied along the back downward, drawn through between the thighs, over the perineum, up over the abdomen, to the centre of the girdle in front. This vertical section consists of two separate leaves of muslin. Its mode of application is this : The inner leaf of the vertical section is placed in cold water, allowed to remain therein for some time, and then wrung out thoroughly. The bandage having been put on (and the vertical section attached to the girdle by buttons), the wet leaf is pressed down upon the vertebral column and upon either side of it, passed through between the thighs upon the perineum, and up over the abdomen to the girdle in front, where it is affixed. The outer, or dry leaf, which, if impermeability be desired, can have oiled silk or gutta-percha paper sewed on to it, is laid over the wet leaf, and covers it completely.^ 1 Winternitz, loc. cit. HiEMORRHOTDS 349 (d) Atzperger's or Winternitz's cooling device for the rectum may be used. With the latter we can get, if we so desire, besides the tonic action of the cold, a compres- sion effect upon the tumors, which is also of some advantage.^ The Hemorrhoidal Bandage. The dietary regulations, and those as to exercise, are always appropriate in persons with hasmorrhoidal tenden- cies, no matter what plan of treatment be followed. The massage treatment may be employed alone, or in combination with hydropathic procedures. Of the hydropathic procedures described, one or more 1 Winternitz, loc. cit. . 350 CONSTIPATION IN ADULTS may be employed, alone, or in combination with massage. The cold injection, as especially efficacious, should always constitute a feature of the plan of treatment. The combination of massage and hydrotherapy makes the treatment more effective, and gives quicker results. As regards the administration of medicines, it may be said that, if the mechanical treatment above described can be carried out fully and faithfully, medication is unnecessary ; otherwise, we may avail ourselves of certain well-known remedies that tend to tone up and invigorate all the structures of the bowels, and to stimulate their functional activity, to fortify the good results obtained with other procedures. These remedies, which have already been referred to more in detail in the chapters devoted to atonic constipation, are : strychnine, physostigma, and ergot. These may be given alone or in combination. Nux vomica or strychnine should be given in very small and more frequently repeated doses. It has been my experience that, in this way, a better effect is obtained. Ergot or ergotin can be administered more freely. Belladonna, which, in small doses, is said to stimulate peristalsis,^ may be prescribed with one or the other of the remedies named. The formula above, given for a combination of physostigma (strychnine or nux vomica can take its place, if preferred), ergot, and belladonna, may serve very well here. We may have recourse at times, with advantage to the patient, to some of the remedies belonging to the group of hepatic stimulants. Hydrastis ^ has been highly commended as a very efficient remedy. It is used both internally and locally. Internally it is given in doses of five to ten drops of the tincture of Hydrastis Canadensis in a wineglassful of water three or four times daily. Locally an infusion or decoction of the bark is injected into the rectum ; the tincture can be used for the same purpose, 3 ss-i being mixed with one or two ounces iBrunton, T. L., Textbook of Pharmacology, Therapeutics, etc., 1888. 2 Phillips, Materia Medica and Therapeutics. HAEMORRHOIDS 351 of cold water, and injected into the rectum before rising in the morning or on retiring at night.^ In conditions of torpid liver or of marked biliousness ^ we may give with our strychnine or ergot, small alterative, if the term may be allowed, doses of rhubarb, euonymin, juglandin, or of stillingia. Purgatives should, of course, be avoided. If, however, cir- cumstances compel us to resort to them in order to keep the bowels soluble, the mild saline laxatives, as magnesia sulphate, cream of tartar, Rochelle salts, etc., are to be preferred. These may be combined with sulphur, which at one time was supposed to have some special influence over this affection, or with rhu- barb or with jalap or with senna, as in the Pulveris Crlycerrhizce Co.^ as may seem most appropriate. 51 Potass. Bitartrat. 3 iii Sulphur Flor. 5 i Mix thoroughly. Sig. Take two tablespoonfuls of the powder and mix in a cup or glass with sufficient molasses to make a thin batter. Of this take one to two teaspoonfuls every morning and evening, sufficient to keep the bowels easily and painlessly moved. ^ Magnesia. Sulphur. (F. Barker) ^ Magnesia. Carbonic. Potass. Super Tart. Sulphur Sublimat. aa §ss Mix thoroughly. Sig. From a teaspoonful to a tablespoon- ful in a glass of sugar water every morning. 5 Pulv. Jalap. (Ellis) * Potass. Bitartrat. Potass. Nitrat. aa § ss Confectio Senna. § i Syr. Simpl. q. s M. ft. Electuarium. Sig. A bolus of the size of a hazelnut three times a day. 1 Ringer, Therapeutics. 2 Brunton, T. L., Disorders of Digestion, etc. * Lectures on the Puerpural Diseases. * J. C. Wilson, Complete Medical Formulary. 352 CONSTIPATION IN ADULTS Soda. Sulphat, (Rosenheim) i Pulv. Khei Radic. Sulphur, depurat. aa 10. ( = 3 ii ss) M. ft. pulv. Sig. About one-fourth teaspoonful {Messer- spitzvolV) at a dose. In debilitated or anaemic persons, an aloetic pill with or without iron will sometimes be better borne than the salines. 5, Pulv. Aloe Socotrin. (F. Barker) 2 Sapon. Castil. aa 3 i Extract. Hyosciam. 3 ss Pulv. Ipecac. grs. v M. ft. pillul. (argent.) No. XX. Sig. One pill morning and evening. In anaemic cases a scruple of sulphate of iron is ordered in the above formula. Various local applications have been recommended. These may be in the form of fluids to be injected into the rectum (as the fluid extract of ergot diluted with two parts water, ergot 3ii, aqua 3iv), in the form of sup- positories or of ointments which are applied to the tumors directly.'^ Dr. J. B. James reports the successful treatment of haemorrhoids solely by the application of calomel with the finger to the tumors.* The local applications are more particularly indicated when the tumors are extruded and inflamed and painful. 1 Loc. cit. ^ See " Formulary." 2 Loc. cit. ■* British Medical Journal, February 20, 1892. CHAPTER XXIX OIL INJECTIONS An application or method of treatment, already re- ferred to in the chapter on " Spastic Constipation," highly recommended by Kussmaul and Fleiner, and already favorably mentioned by older writers, is the injection of oil into the rectum, — the oil clyster. In all ailments of the intestinal tract not accompanied by motor disturbances, oil injections are indicated. More precisely, its therapeutic indications may be summarized thus : I. Wherever, from functional disturbance or organic change, the evacuation of faeces is inhibited, so that stag- nation and accumulation thereof occurs. II. In all forms of mechanical obstruction to the dis- charge of faeces, by compression of the bowel by abnor- mally enlarged abdominal organs, as liver, spleen, uterus, ovaries, or prostatic gland ; by constriction of the gut by pseudo-membranous peritoneal exudation; by stenosis from cicatrices or neoplasms; by sudden bending of a section of the large intestine. III. In all cases of intestinal irritation ; in subjective troubles of diverse forms, colicky pains, circumscribed inflammatory processes ; in proctitis, colitis, typhlitis ; in ulceration, tubercular or dysenteric, — the oil clyster 353 354 CONSTIPATION IN ADULTS is indicated, and even though evidences of involvement of the peritoneum present themselves. Excepted are all irritative conditions of the intestine accompanied by increased peristalsis, whereby contenta of the small intestines, considerable quantities of unchanged bile and natural pancreatic juice, are thrown rapidly into the colon. In these cases an injection of oil would be followed by a saponification of the same as it came in contact with the bile and pancreatic juice, and the setting free of oleic acid and the formation of glycerines. These, having a stimulating action upon the intestine, would ag- gravate the irritation already existing. The oil clyster is said to be of exceptional utility in the bowel complaints that accompany ailments of the stomach ; also in anaemic individuals and such whose nutrition is. much impaired. Technic of the Oil Clyster. — The very best of olive oil, — the virgin oil, if it can be obtained, — or the purest of cotton-seed oil, only should be used. The other oils, occasionally employed, as poppy-seed oil or rape-seed oil, are not extant in this country. To avoid thermic or mechanical irritation of the mucous membrane of the large bowel, whereby peristalsis might be at once excited, the oil should be warmed before it is injected into the bowel. Oil is warmed by placing the bottle or vessel containing it into a vessel of hot water. The ordinary fountain syringe (whether the reservoir be a rubber bag or a tin or glass can) answers very well. The rectal point should have a calibre sufficiently large to OIL INJECTIONS 355 be commensurate with the slow outflow of the oil. Its borders should be smooth and well rounded. The follow- ing figure indicates what, according to Fleiner, its shape should be. ^^^^^^^^^^ (Can be made of hard rubber, bone, or glass.) The patient is placed in the horizontal position on a bed or couch, on the dorsum or on the side. The pelvis is ele- vated (20 to 25 cm. = 8 to 10 inches), especially if it be de- sired to reach further portions of the colon, by placing a -firm (non-compressible) pillow, or a blanket properly folded, beneath it. In this, as in the knee-elbow position, a nega- tive pressure is developed in the pelvic organs which exer- cises an aspirating action upon the fluids thrown into the rectum. Over the pillow or blanket a rubber sheet or oil-cloth is placed, so as to avoid soiling by the oil. The reservoir of the syringe is elevated above the rectum to a height of about 50 cm. ( = about 20 inches) or more and the oil allowed to flow in. After taking the injection, the patient should remain lying down for at least one hour. In cases of constipation with accumulation and indura- tion of faeces, where the injection should reach up into the colon as far as possible. 400 to 500 c. cm. of oil are required for the injection for adults ; for children, 50 to 150 c. cm., according to the age. In conditions other than constipation, in affections of the colon descendens, 356 CONSTIPATION IN ADULTS of the sigmoid flexure, or of the rectum, 100 to 150 c. cm. (can be injected with a hard rubber syringe) ; for children, 30 to 50 c. cm. will suffice. The outflow of the oil is, as readily understood, rather slow. It takes from fifteen to twenty minutes for 400 c. cm. to flow out completely. The evacuation does not at once follow the injection. Usually several hours elapse before an evacuation occurs. If the gut be very much filled with hardened fgeces, it may be necessary, if the required effect is not produced by the oil in three or four hours, to follow it with an injection of warm water. A single application will not suffice, according to Fleiner, to have the oil reach the caecum, even by changes of posi- tion on the part of the patient. A daily repetition of the clyster is therefore necessary, if any benefit is to be de- rived from this method of treatment. When the maxi- mum effect has been obtained, it can be recognized by the character of the stool, which will now resemble very much the contents of the small intestines, and sometimes even give biliary color-reactions. Sometimes the maximum effect is obtained in two, at other times it will be three, or even more, days. After the maximum effect has once been obtained, the clysters are given at intervals of two or three days, or even longer, according to the indications in the case. The quantity of oil is also diminished to 250, to 200 c. cm. The oil discharged from the bowels shows, very fre- quently, marked changes : the most striking is the change in color, which may run all the shades from dark yellow to olive green. Besides the fsecal odor, it sometimes OIL INJECTIONS 357 acquires a sour smell, and a chemical examination shows an increase of acidity.^ If abnormal fermentative or putrefactive processes are to be combated, one or two per cent of salicylic acid may be added to the oil.' The oil acts both mechanically and chemically. By its mechanical action, which sets in already in the lowest segment of the gut, it loosens and detaches the scybala from the intestinal parietes, penetrates the indurated f^cal masses and softens them, and indirectly, through the softened faeces, excites peristalsis. Its chemical action is this : When it is brought in con- tact with unchanged bile and normal pancreatic juice, a process of saponification is set up, in the course of which oleic acid is set free and glycerine is formed, and both of these products have an irritating effect on the intestinal parietes, and thereby excite peristalsis. Summarized, the effects of the oil are : It detaches the scybala from the intestinal wall. It softens the indurated fteces. It has an emollient, soothing effect upon irritated tissues.^ It stimulates peristalsis. It inhibits the resorption of water (from the faBces) by the mucous membrane. Usually the oil clyster does not cause any disturbance at all ; occasionally, only, the patient experiences an un- pleasant sensation, as if something were crawling in him ^ Fleiner, Berliner klin. Wochenber., 1893. 2 Rosenheim, loc. cit. 3 T. Lauder Brunton, Pharmacology, etc. 358 CONSTIPATION IN ADULTS (searching out the bowels, some patients described it), that may disturb his sleep. This passes away, however, in a very short time. It is absolutely necessary to cleanse the syringe thoroughly after each injection. The rubber tube is filled with water and hung up in JJ form ; after a time the water is allowed to fl.ow out at both ends. This process is I'epeated several times. If the instrument cannot be perfectly cleansed in this way, a little absolute alcohol will quickly remove all the particles of oil remaining.^ 1 Fleiner, loc. cit. CHAPTER XXX SOME OTHER METHODS OF TREATING CONSTIPATION (THAT HAVE BEEN RECOMMENDED) I. Stretching of the Sphincter Ani for Constipation (not due to local lesion). In 1889 Dr. C. Cleveland ^ reported some cases of con- stipation treated by forcible dilatation of the sphincter ani, and with favorable results. Gant ^ has likewise re- ported favorably, though he does not confine himself to this procedure alone, but makes use also of massage and electricity. It is a question, therefore, how much of his success can be attributed to the measure under considera- tion. Mathews^ expresses himself rather cautiously. It can be readily understood how forcible dilatation may be of benefit in those cases of abnormal contraction of the sphincter that are occasionally seen in the hysteri- cal and the neurasthenic* That the cases relieved were of such a character, seems demonstrated by the fact that almost all of the cases reported are females, and all with either well-developed hysteria or neurasthenia, or at least a much-depressed and irritable nervous system. 1 New York Medical Record, March 9, 1889. 2 « Non-Medicinal Method of Treating Constipation," by S. C. Gant, The Medical Herald, St. Joseph, Missouri, March, 1893. ' Loc. cit. * See « Spasm of the Sphincter," Chapter XX. 359 360 CONSTIPATION IN ADULTS How it could be of any possible benefit in atonic states of the intestine is rather difficult to understand, despite attempted explanations. At the utmost the benefit here would be but temporary and not commensurate with the trouble and the suffering caused, especially when we have other methods that are in all cases certain of success, without any of these drawbacks. The manner of effecting forcible dilatation of the sphincter ani has been already described in a preceding chapter. It re- mains only to be said here that there is also a more gradual process, as suitable in the condition under consideration as the more forcible procedure, and much more convenient, both for the physician and the patient. The gradual dilatation is made by means of soft rubber rectal bougies.^ II. The Application of Boracic Acid.'' Flatau treats habitual constipation with boracic acid locally applied. His method of treatment is this : Where, in consequence of marked relaxation or of chronic proctitis, the rectal mucous membrane protrudes more or less through the anal orifice, the nates are sepa- rated, the anal parts washed with cold water, well dried, and about ten to twenty grains (a Messerspitzvoll = what will go upon the tip of a dinner-knife) of finely powdered boracic acid is either dusted strongly upon the protruding rectal mucous membrane or rubbed into it, with a circular movement, with the tips of the fingers. If there be no such protrusion of the mucous membrane, the powder is insufflated into the rectum. For insuffla- 1 Gant employs this method. Loc. cit. 2 Th. S. Flatau Berliner klin. Wochenschrifl, 1891. OTHER METHODS OF TREATING CONSTIPATION 361 tion a coarser powder, one still somewhat granular, is better and more effective. The applications should be made by the physician, ex- Whitehead's Instrument FOB Gradual Dilata- tion. mi m m i Wm cept in cases of protrusion of the rectal mucous membrane, where the patient can be taught to apply the powder himself. After the application, the patient should remain in the 362 CONSTIPATION IN ADULTS horizontal position for a little time, so as to retain the powder in place. In from one-half to three hours peristaltic movements, which can be noted upon the abdominal parietes, are ex- cited in the region of the colon, and abundant watery discharges follow. In some cases there are in the first days three or four stools per day. At the outset of the treatment patients must be in- structed to obey the slightest indication of a call of nature, for if the slight be disregarded the stronger may not follow. The applications are made at first daily ; then when the intestines show more activity, every other day ; then twice a week, once a week, twice a month, once a month, and then cessation. The claim is made that the treatment is not injurious. From the exposition of Flatau, it is evident that the application of boracic acid acts in the same manner as does glycerine, and that it has no special advantage over the latter. Moreover, it may prove injurious. A case is reported where packing of the vagina with boracic acid produced pronounced poisoning. That no such effects have been as yet noted from the applications to the rectum, may be due to the small number of cases in which the treatment has been tried. It is also very self-evident that a mere irritation of the intestinal tract, whether by bougies or by drugs, locally applied or internally administered, cannot overcome the fundamental difficulty, the atony of the intestines. OTHER METHODS OF TREATING CONSTIPATION 363 III. Treatment by River Gravel {FlusskieseV)} Kaczorowsky has had success in treating habitual con- stipation with river gravel. He directs that the patient take a glass of cold water every morning on arising, on a fasting stomach. He reo-ards this as the very best and most efficient way of softening and thinning the intestinal contents. He also directs the use of Graham bread, and gives other dietary regulations such as have been already set forth. The mechanical measures are the best and simplest, and are not followed by any unpleasant side-effects. From this standpoint he has made use, besides, of the cold-water injections, of river gravel (Flusskiesel) or, rather, river sand washed off with hot water. Of this, a teaspoonful to a tablespoonful is taken twice daily. It is taken plain without any other menstruum or envelope, and washed down with cold water, drunk after it. It is much more effective if the grains of sand are of the size of flax seeds. From an aesthetic point of view the gravel could be replaced with coarsely ground marble dust; the antacid properties of this might be an additional advantage. From his rather large experience, Kaczorowsky believes its use indicated in all cases of habitual constipation. He has had remarkable success with it in the treat- ment of spastic obstipation in young, nervous persons with hyper-excitation of the genital spheres. He finds it also indicated in the constipation dependent ^ Kaczorowsky, Asrodkach wyprizniajacychjelito, wseczegole o Zwirze- Przeglacl lekarsi, No. 15-17, Krakow, 1886. " On the Intestine Evacuating Remedies, more especially as to River Gravel," Virchow u. Hirsch, Jahresbe- richt, 1886. 364 CONSTIPATION IN ADULTS upon chronic heart and knig affections, with consequent anasmia and debility. Also in the chronic catarrh of any section of the intestinal tract. IV. Treatment by Suggestion. According to Dr. A. Forel, constipation can be readily and quickly cured by the "Suggestion" method of treat- ment (hypnotization and suggestion).^ 1 Die Heilung der Stuhlverstopfung durch Suggestion, etc., von Prof. Dr. A. Forel, Director der Irrenanstalt Burgliolzli, Zurich, Berlin, 1894. CHAPTER XXXI TREATMENT OF CONSTIPATION IN OLD PEOPLE Constipation is one of the more frequent troubles of old age. Yery often it is only an aggravation of a cos- tive condition of the intestinal tract that has long pre- viously existed, and even where this is not the case it is readily accounted for by the various changes that char- acterize this period of human existence. An atony of the whole muscular system with a ten- dency to atrophy. A slowing of all the physiological functions. A diminution of the various secretions. Moreover, as a result of these changes, less exercise is taken, and there is therefore diminished oxygenation ; less food is taken, and what is taken is of a more concentrated character, and there is therefore diminished detritus. Under these conditions nothing can usually be done toward a restoration to the normal, but very much can be accomplished to make the patient comfortable. I. First and foremost we will see to the diet. Though we cannot advise much coarse food, we have, nevertheless, several articles that are of great utility, and still compati- ble with the requirements of old age. These are : A glass of cold water, the first thing on rising in the morning. 365 366 CONSTIPATION IN ADULTS Oatmeal with milk and sugar (milk sugar ^ if it can be had) ; but preferably, if the patient can eat it that way, with (cane) syrup and milk for breakfast. Molasses (cane-syrup) or fruit jellies, eaten with bread. Fruit puddings (see formulary). Baked apples, stewed fruits, compots, morning and evening. II. Exercise. — It is important even for the old to take some exercise, both for the reason that it prevents the muscular system from relapsing into a state of lethargy by thus constantly arousing it, as, also, because it effects increased oxygenation of the blood and this more vigorous assimilation and greater excitation of muscle. I believe it can be maintained as an undeniable fact, that the characteristics of old age, in so far as loss of vigor is concerned, are less marked in those who continue to work, to keep up a state of activity, than in those who, naturally indolent, fall into a state of almost abso- lute inertia. The exercise should be taken, as already indicated, in the open air ; a good walk, keeping well this side of the limits of fatigue ; horseback riding, carriage riding, in the park or open country, — all commensurate with the re- maining degree of vigor. III. As regards the treatment, more properly speaking, it may be said that, as a rule, the more forcible measures of the mechanical method will do no good ; massage is of no benefit, and of hydrotherapy, only the clyster (hot or 1 Boas believes that sugar of milk has some laxative properties. Ronth (on "Infant Feeding"), however, holds that it tends to allay intestmal n-n- tation, and to check diarrhoea. TREATMENT OF CONSTIPATION IN OLD PEOPLE 367 cold) and the cold bath (with persons accustomed thereto) are available and also advantageous. Here the well-regulated administration of drugs will be of service. The milder of the purgative medicines only should be resorted to. Moreover, when a certain article of this group has ceased to be effective in a proper dose, we should not keep on with it, increasing the quantity administered, until it is inordinately large, or until the system ceases to react to the agent altogether, but rather change it, — take up another remedy and lay this one aside. By doing this, we prevent a greater exhaustion of the intestinal tract and aggravation of the constipation, and also reserve a remedy; for it will regain its power at a later period, when the system wdll cease to respond to this one as it did to the other. A well-regulated dinner-pill, for which there are a number of formulae all more or less alike, taken an hour or two after the midday meal, or just before retiring at night, will be all that will be required with many persons. When this ceases to be effective, or at the outset, if we so prefer, we may prescribe cascara sagrada (as cordial, elixir, or pill) or the confection of senna (dose 3 i-ii, once a day), or some other lenitive electuarium.^ A good pill, that acts both kindly and efficiently, is composed as follows : 3 Extract. Jugland. grs. ii Extract. Rhei gr. i Extract. Nuc. Vomic. gr. ^ Extract. Hyosciam. (Engl.) gr. i M. ft. Mass. et ft. pillul. I. Sig. One pill at bedtime. 2 1 See " Formulary." 2 For other formulae, see "Formulary." 368 CONSTIPATION IN ADULTS If no distress is caused thereby, a purgative need not be taken but every other day, or even twice a week only. In cases of marked sluggishness of the intestinal tract, it may become necessary, after a longer or shorter period of time, to effect a more thorough clearing out of the bowels. We can accomplish this by means of the decoc- tion of rhubarb, the Infusum Laxativum Viennensis,^ the liquor magnesise citratis, a laxative mineral water, or with any of the more active formulae known to physicians. This must be borne in mind as a rule governing the use of purgatives in the aged, that no agent or formula that will gripe must he prescribed ; old people stand such suffer- ing very badly. It should be our aim in all cases to maintain the intes- tinal function by means of the dietary regulations and the use of injections, reserving our medicines for those periods when the measures named will cease to be effective, and for those occasions when a more thorough emptying may be required. In many cases we will succeed so well that the bowels will act almost normally. When, however, for one reason or another this cannot be done, or when such treatment is not effective, then we will direct the regu- lar administration of medicines in the manner already indicated. 1 Same as Mixtura Sennse Co. The addition of Syr. Rhei Aromat, in the proportion of one to three or four of the Mixture, will correct any tendency to gripe that it may have. CHAPTER XXXII FORMULARY An evacuation, though not always a satisfactory one, may be obtained by means of an injection of glycerine. One-half to one ounce of glycerine is injected into the rectum with a hard rubber syringe. Or the glycerine can be introduced into the rectum by means of a suppository. It is applicable more especially in those graver cases of acute intestinal disease where an evacuation of the rectum, at least, and a discharge of flatus would be desirable, but where the use of even mild laxatives is contraindicated as fraught with possible danger. Mild and usefid laxative preparations and formula. Elixir or Cordial of Cascara Sagrada. Extract. Fluid. Cascara. Sagrad. 3 vi Tinct. Nuc. Vomic. 3 ii M. Sig. x-xv drops three or four times daily. ]J Extr. Cascar. Sagrad. fluid.^ 3 i Tinct. Nuc. Vomic. gtt. x Tinct. Belladonna. m v Aq. Si M. ft. haustus Sig. (this dose) to be taken twice a day. 1 James D. Staples, Hospital Gazette. New York Medical Record, 1892. 369 370 CONSTIPATION IN ADULTS Tonic laxative (formulary East Side Dispensary). 3 Extr. Fl. Cascar. Sag. 25. = 3 vi ^ Tinct. Cinchona. 15. = 5 ss Tinct. Nuc. Vomic. 5. = 3 If Aq. et Glycerine q. s. ad 60. = q. s. ad 5 ii M. Sig. Dose one to two teaspoonfuls, repeated every three or four liours. Pulv. Jalapae Co. very useful in htsemorrhoidal conditions. Infusum (aut decoctum = frequently prepared as such) Rhei. U. S. Pharm. 3 ii to the O ss ; dose, half to one wineglass- ful. British Pharm. 1:40; dose, one to two ounces. Germ. Pharm. 1 : 12 ; dose, one to two tablespoonfuls. Very useful in various hepatic ailments. Alkalies or acids, as may appear indicated, can be added thereto. Tinct. Rhei : dose, one to two ounces. Tinct. Rhei et Gentian. Pulv. Rhei Co. 3 i to 3 i every three or four hours. A very excellent formula for all those conditions wherein a laxative would be very useful, and where yet the great- est care must be exercised not to excite but the very mildest of peristalsis. Infusum Laxativum Viennensis. [Mixtura Sennoe Co., senna, manna, Rochelle salts, etc.), a very pleasant, and, at the same time, effective purge. Its action can be regu- lated by an increase or diminution of the dose. For a mild effect give one to two tablespoonfuls every hour or two ; for a more energetic action, one-half wineglassful every two hours. Pulv. Glycerrhizae Co. [Pulv. Liqueritice Co), grs. xv-xx FORMULARY 371 every two or three hours. Useful in catarrhal conditions of the respiratory tract. Pills Resin. Podopliyllin Extr. Colocynth. Co. Extr. Hyosciam. Ole. Tiglii Ole. Menth. Pip. M. ft. pillul. No. XII. Sig at bedthne). grs. VI grs. xii grs. xii gtt. i gtt. i Dose one pill (usually taken ^ Extr. Colocynth. Co. Pulv. Rhei Extr. Alcoh. Nuc. Vomic. Podophyll. Res. Extr. Belladonna. (Engl.) Extr. Hyosciam. M. ft. Mass. et ft. pillul. No. I. Sig. repeated in the morning if necessary. gr. 1 ss gr. i gr. i gr. i One pill at bedtime ; B, Extr. Colocynth. Co Extr. Hyosciam. Pulv. Aloes Socot. Extr. Nuc. Vomic. Podophyllin, p. Ipecachuan., p. aa M. ft. pillul. (argent.) No. XII. at one dose. ^i (Fordyce Barker) ^ grs. XV grs. XV grs. V gr. 1 Sig. Two pills to be taken ^ Podophyllin grs. iii Extr. Colocynth. Co. Sapon. Castiliens. aa grs. iii Extr. Alcoh. Nuc. Vomic. grs. v Extr. Hyosciam. grs. vi M. ft. Mass. et divid. in pillul. No. XII. Sig. One pill every morning. ^ Loc. cit. 372 CONSTIPATION IN ADULTS Formula for protracted use, as in the constipation of the old : Confectio Sennse. Dose, 3 i-ii (not to be prescribed when ■ dyspepsia complicates the constipation). Electuarium Lenitivum Wintheri. — Manna, 2 ; syrupus limonis, 10 ; pulpa tamarindorum, cassia prseparata, aa 2 ; folia sennse, cremor tartari, aa Dose : one teaspoonful. Electuarium Mannae. — Manna, saccharum, aqua foeni- culi, aa 2 ; pulvis rad. iridis, | ; oleum amygdalarum diilcium, 1. Dose : a heaping teaspoonful.^ A more energetic preparation of this character, and adapted to cases of extraordinary lethargy of the intestine, is the confectio scammonii of the German or British pharmacopeia. These formulse, though old-fashioned and rather forgotten, are, nevertheless, very useful for the persons and purpose that they have been here recommended for. Pillule Aloes et Assafoetidae (U. S. P., dinner pill). Pillulge Aloes et Mastiches (U. S. P. = Lady Webster dinner pill). 5 Podophyllin 0.3 = grs. ivss (Nothnagel)^ Extract. Aloes Extract. Rhei aa 3.0 = grs. xxxxvi ss Extract. Taraxac. q. s. M. ft. pillulce No. XL. Sig. One pill at bedtime. 1 Strumpf, Allgemeine Pharmakopoe. 2 Wiener mediz. Presse, loc. cit. FORMULARY 373 ^ Pulv. Rhei Siv (Dr. B. Lee) ^ Piilv. Aloes Siii Pulv. Myrrh. 5ii Sapo. Hispanien. 5 ii ss Olei Cajeput. 3i M. The powders are to be rubbed together, and the soap then worked in, afterward the oil. The well-mixed mass is kept in a tight-stoppered bottle. The fresher the powder, the better it is. Three grains make an effective dose which does not irritate. 5. Extract. Jugland. grs. ii Resin. Podophyllin gr. Pulv. Rhei Rad. gr. i Extr. Hyosciam. (English) gr. i M. ft. Mass. et ft. pillul. No. I. Sig. One pill at bedtime. ^ Podophyllin gr. yL (Brundage)^ Extract. Belladonn. gr. J^- Extract. Nuc. Vomic. gr. ^ Extract. Hyosciam. gr. ^ Pulv. Capsic. gr. ^ M. ft. pillul. No. I. Sig. Take at bedtime. Dose : one to two pills. It is directed that the pill be taken nightly for a week, then every other night, until natural evacuations follow. For Constipation with Flatulence ^ Extract. Colocynth. Co. gr. | Terebinth. Veneta. gr. Pulv. Aloes Socot. gr. Extract. Nuc. Vomic. gr. Extract. Hyosciam. (English) gr. i M. ft. Mass. et ft. pillul. No. I. Sig. One pill two to three times a day. 1 New York Medical Record, 1894. 2 Lilly, Handbook of Pharmacy and Therapeutics. 3 i i ss 374 CONSTIPATION IN ADULTS 3 Extract. Senna, fluid. (p. Barker) ^ Syrup. Zingibr. aa 3 vi Tinct. Jalap. 5 ss Tinct. Nuc. Vomic. gtt. 40 M. Sig. A tablespoonful in a wineglassful of water and sugar. For Constipation with Haemorrhoids Pulvis Antih8emorrhoidalis.2 5 Pulv. Ead. Rhei 3 parts Potass. Bitartaric. Depur. Flores Sulphur. Magnes. Carbonic. aa 3 parts Senna. Folior. Semen. Foenicul. aa 2 parts M. bene et adde Eleosacchar. Foenicul. 16 parts M. ft. pulv. Sig. Dose 3 i (can be taken in the morning before breakfast, or at bedtime). ^ Sulphuris loti 3 i ss (Ellis) ^ Confection. Senna. 5 ii Potass. Nitrat. 3 i Syrup. Aurantii Cortic. q. s. M. ft. Confectio. Sig-. One to two drachms twice a day. 5 Pulv. Jalap. (Ellis) ^ Potass. Bitartar. Potass. Nitrat. aa 5 ss Confection. Senna. S i Syrup. Simplic. q. s. M. ft. Electuarium. Sig. A bolus of the size of a hazel- nut, three times a day. 1 Loc. cit. 2 Strumpf, Allgemeine Pharmakopoe. s Wilson, Complete Medical Pocket Formulary. FORMULARY 376 Ointments For all Forms of Rectal Pain ^ 'S^ Succus Conii 5 ii boiled down to 3 i ss Lanoline q. s. ad S i M. ft. Ungt. Sig. Apply locally. For HoBmorrJioids Cerat. Simpl. 3 vi Vaselin. 3 iii Pic. Liquid. 3 i ss Extr. Belladonna. 3 i ss Acid. Gallic, sive Tannic. . 3 i M. ft. Ungt. 3 Ungt. Gallse Co. 5 i (F. Barker) 2 Extr. Opii Aquos. 3 i Solut. Ferri persulphat. 3 i M. ft. Ungt. Sig. Apply to the tumors. ^ Tinct. Hamamel. 3 xii Lanolin. 3 vi Petrolat. ad S xvi M. ft. Ungt. Extract of Garlic 1 part^ Olive Oil 2 parts M. to be applied to the tumors, or, if they be concealed, a drachm of the mixture is injected into the rectum. M. ft. Unguent. 1 Medical Standard, Chicago, 1888. 2 Lqc. ' H. Kinnard, Pacific Medical and Surgical Journal. New York Medical Record, 1887. * Wilson, Complete Medical Pocket Formulary. Pulv. Opii Unguent. Pic. Liquid 3ii 5i (Ellis)* 876 CONSTIPATION IN ADULTS Hydrarg. Chlorid. Mit. (Calomel) jii (Bartlett^ Unguent. Petrolei (Vaselin.) M. ft. Unguent. Suppositories (for concealed hemorrhoids) 15 Acid. Gallic. Extract. Ergot. ga gr. i Extract. Belladonn. (English) gr. i Extract. Hyosciam. .(English) gr. i Ole. Theobrom. [ M. ft. Suppositor. No. 1. Sig. Introduce one into the rectum night and morning. Extract. Kramer. 3 ii (Pancoast) 2 Pulv. Opii grs. v Ole. Theobrom. 5 ss M. ft. Suppositor. No. X. Sig. Use one morning and night. 5 Acid. Tannic. 0.06 = gr. i (Rosenheim) ^ Chrysarobin. 0.1 = gr. iss Extract. Belladonn. (seu Opii) 0.02 = gr. ^ Ole. Theobrom. 2.0 = 3 ss M. ft. Suppositor. No. I. Sig. Introduce one once or twice a day. Ointment (for external piles) 5 Chrysarobin. grs. xvi (Kossobudski) * Iodoform. grs. vi Extract. Belladonn. grs. xii Vaselin. 3 vi M. Sig. A small quantity to be applied to the tumor sev- eral times a day, the parts having been previously washed with a solution of carbolic acid 1 to 50, or of creolin 1 to 100. ^ Wilson, Complete Medical Pocket Formulary. - Complete Medical Pocket Formulary. 8 Loc. cit. * Complete Medical Pocket Formulary. FORMULARY 377 Wash for Bleeding Piles ]^ Alum. pulv. 3 ii Acid. Tannic. 3 ss Aqu. Destill. 5 v M. Sig. One-half to be injected at a time, and to be re- tained as long as possible. Acid. Nitric. f i ss — i (Ringer) ^ Aqu. Destill. f i viii M. ft. Lotio. Sig. Apply as a wash. Schmey reports that he has had great success in the treat- ment of haemorrhoids (protruding) with the daily applications, by means of a camel's-hair pencil, of a two per cent (2%) solution of silver nitrate. The applications are altogether painless.^ Formulae for Injection — Method of Treatment (of piles, extruding) 5 Glycerin. 3 ii ss (Meniere's)^ Acid. Phenic. (Carbolic.) gtt. xx Morphia. Sulphat. grs. v M. Sig. Inject five to ten drops into the tumor. 5. Acid. Salicylic. 3i Glycerin. 3 iss M. rub the two well together, and add Acid. Carbolic. 3ii M. then rub together Borac. 3 i Glycerin. 3 i ss Now mix the two mixtures thoroughly together, and allow to stand until clear. Sig. For small tumors three to five drops, for large tumors five to eight drops, to be injected.* ^ Complete Medical Pocket Formulary. ^ Allgemeine medic. Centralzeitung, 1895, No. 73. Therapeut. Monat- shefte, October, 1895. s jVeio York Medical Record, 1886. * A Shuford, Neio York Medical Record, 1887. 378 CONSTIPATION IN ADULTS Dietetic Preparations Apples. Baked Plain. — Procure some highly flavored apples (others, except as to aroma and taste, will answer as well), — hard winter apples are to be preferred, — take the core out at the centre by boring, and fill the cavity thus created with sugar. Put into a dry pan, and place in a good hot oven. Ordinarily the apples will be thor- oughly baked in about sixteen to twenty minutes. To make certain that they are well done, they can be tested by thrusting a fork into them. Baked Plain. — Take apples as above, cut them in halves, remove the core, etc., refit them together, and tie them somewhat loosely in pieces of very thin paper previ- ously smeared with good fresh butter ; then place them in the oven at a moderate, steady heat for twenty-five minutes. Remove the paper; grate some fine loaf-sugar over them, set aside to cool, and serve when cold.^ Baked loitli Syrup. — Take of the finest loaf-sugar half a pound, and of soft, filtered water eight tablespoonfuls ; boil down together at a gentle heat in a small stew-pan for a quarter of an hour. Then pare three good, well- flavored apples (others will answer), removing the core by boring (as with a slicing blade), place them in a shallow tin pan, pour over them the syrup just prepared, add a wineglassful more of water, and acidulate with ten drops of lemon-juice. Place in the oven at a moderate, steady heat for thirty minutes. Remove into a dish, set aside to cool, and serve when cold.'^ 1 Morgan, Indigestion, Constipation and Haemorrhoids, London. ^ ibid. FORMULARY 379 Steioecl. — Pare and quarter three or four or more fine apples, — having first prepared a syrup as above directed, — add a teaspoonful of lemon-juice and three very thin strips of lemon-peel; put all these ingredients into a shallow stew-pan, and place over a very gentle fire, so that a barely simmering heat is maintained ; after they have stewed thus for fifteen minutes, pierce the apples with a fork from time to time to ascertain when soonest they become thoroughly softened ; as soon as this is the case, pour them off with the syrup ; set them aside to cool, and serve when quite cold.^ Or, pare the apples, cut them in quarters, and put into a stew-pan with enough water to reach half the height of the apples ; close the stew-pan tightly, and let them steam until they have been well done (ordinarily one-half to three-fourths of an hour). They are then taken off, allowed to cool somewhat, re- duced to a pulp, and seasoned with sugar and lemon-peel (the lemon-peel can be omitted if desired) to suit the taste ; then put in the oven again for three to five minutes to allow the seasoning to become thoroughly incorporated therein. Pour off into a cold dish, and serve when quite cold. If preferred, the seasoning can be put in at the outset. Stewed ivith Raisins, Prunes, or Figs. — Prepare the apples as above, and add to them about one-fifth the quantity of raisins cut into halves, or one-eighth the quan- tity of prunes opened and stoned, or one-eighth the quan- tity of figs sliced up into smaller pieces. After the completion of the boiling, when the apples are well done, mash the fruits together to a pulpy mass, and season with sugar and lemon-peel as above directed. 1 Morgan, loc. cit. 380 CONSTIPATION IN ADULTS Marmalade (can be eaten as soon as cold, or preserved in jars for a length of time). — Take eight moderate sized and well-flavored apples, — such as will boil down to a smooth pulp are required, — pare and remove the core, place in a basin, and squeeze over them the juice of a lemon. Then prepare a syrup by boiling down a pound of the finest loaf-sugar with a tumblerful of water for twenty minutes. When this is done, add the apples and lemon-juice — if cane syrup or molasses is used, pour this over the apples — and keep at a barely simmering heat until the apples are all reduced to a pulp. When this object is obtained, submit the stew-pan to a greater heat; add a little grated lemon-peel, stir briskly and incessantly until it becomes thoroughly consistent, when it may be stored in jars, and set aside to cool.^ For the constipated [cane] syrup or molasses is much to be preferred in the preparation of the various dishes described. Grated Apple-Pudding {a most delicious dish). — Grate six large tart apples — of good flavor if they can be had — into a large bowl ; add half a cup of sugar, raisins, a few pounded almonds, the yolks of three eggs, and the whites thereof, after having been beaten into snow. A pinch of salt must be added. Mix all these together, put into a pudding-dish, and bake in a hot oven for thirty minutes. It can be eaten warm or cold. For the constipated it is best served cold. Prune Butter. — Besides in the common way as a stewed dish, prunes can be prepared as a butter or a paste which can be eaten with bread or with various farinaceous dishes, 1 Morgan, loc. cit. FORMULARY 381 as grits, macaroni, vermicelli, grated noodles, etc., for which it may serve as a top-dressing. It is prepared thus : Take one cup of stoned prunes and one cup of water ; boil in a stew-pan until soft, mash into a smooth pulp, and add the grated rind of half a lemon. Fruit Beverages. — A good substitute for alcoholic liquors when sweet cider cannot be had. Apple Tea. — This drink, which is very pleasant, is best made with fruit previously roasted or cooked dry by open exposure to the heat of the fire, as on the edge of the hob or bars. Four fine apples should be used for every quart of tea required, and the best granulated sugar — about two ounces — should be added. The whole of these ingredients — to which a table- spoonful of lemon syrup may be added or not, according to the taste — should then be placed in a cylindrical por- celain jar sunk in a basin of boiling water, — and boiling water should be quickly poured upon the fruit and stirred briskly for a few seconds, — covered, and set aside to cool ; strained through four folds of muslin, and served as desired. Apple Drink. — Another kind of drink may be made by slicing six full-sized apples into a basin, stoning a quarter of a pound of raisins, and bruising down two ounces of loaf-sugar ; the whole of these ingredients should be thrown together into three pints of boiling water, and kept boiling for thirty minutes. After this the whole should be set aside in a capacious covered jar to cool, and should be strained through a fine hair sieve, and served when cold.' 1 Morgan, loc. cit. 382 CONSTIPATION IN ADULTS Lemon Tea. — Take a large, juicy lemon, cut it in two, and remove the seeds ; put it into a pot with two ounces of water and two to four pieces of loaf-sugar (the sweeten- ing to be regulated by the taste), and boil down to a cup and a half. Can be taken warm as a tea or cold as a drink. Grated Noodles. — Make a stiff noodle dough and grate the same on a coarse grater, dipping in flour occasionally so that it may grate more easily. Put in the oven to dry, being careful not to allow them to brown. Rub to crumbs. Have ready boiling salt water in which to throw the crumbs. Boil thirty minutes, then strain off. Melted butter may be poured over if desired, or any fruit — butter, marmalade, or jelly can be used as a top-dressing. PART II CONSTIPATION IN INFANTS AND CHILDREN CHAPTER I CONGENITAL CONSTIPATION Constipation, as is well known, is one of those ail- ments that is common to all classes of society, from the palace to the hovel, and that is met with at all periods of life, from the infant " mewling and puking in the nurse's arms," to "the lean and slippered pantaloon." The constipation of infants can be divided into two great categories : Congenital constipation. Acquired constipation. Congenital Constipation Congenital constipation may manifest itself (a) At once, immediately after birth, by a failure of discharges from the intestinal canal ; an intestinal obstruc- tion, with all the acute symptoms, appearing in a very brief period of time. (6) Or, as a constipation proper, by a deficiency in the frequency and quantity of fgecal matter discharged from the bowels, with, if the difficulty be not remedied by nat- ure or by man, consequent complete obstruction with all its phenomena, after a longer period. (c) Again, it may manifest itself by occasional par- oxysms of obstruction with complete cessation of evacua- .380 • CONGENITAL CONSTIPATION 387 tion, whilst in the intervals between these paroxysms the alvine discharges may be fairly regular and sufficient in quantity. It depends upon some malformation, malposition, or other abnormality of some portion of the intestinal canal, of the small intestines, of the colon, of the rectum, of the anus. A. Malformations of the Rectum and Anus. — The mal- formations of this portion of the gut which are apparently the most frequent, or, at least, have been most frequently noted, have been thus summed up by Bodenhammer in his classical work on this subject.^ 1. The anus may be more or less preternaturally nar- rowed at its margin, and sometimes for a short distance above. The contraction is not always limited to the anus, but ex- tends occasionally up into the canal itself. This narrowing of the rectum is sometimes found to be due to numerous folds which project from its inner wall into the lumen of the cavity, and obstruct more or less, according to their degree of develop- ment, the performance of its physiological function. The anal opening aud the cavity of the rectum may present all the dif- ferent degrees of stricture, from that into which the smallest probe cannot be introduced to that which opposes but little obstruction to the passage of a small-sized catheter. According to the degrees of stricture, we will have either intestinal ob- struction or one or the other forms of constipation. Sometimes the marginal integument of the anus extends over the border of the sphincter muscle, aud produces thereby both contraction and deformity. 2. The anus and rectum may be normal, but the simple, 1 The Congenital Malformations of the Rectum and Anus. 388 CONSTIPATION IN INFANTS AND CHILDREN thin, and delicate membranous septum of foetal life may still exist, and thus produce a complete occlusion of the anal orifice. The anal aperture is sometimes completely closed by a thick and hard membrane, or a substance analogous to it. 3. The anus may be entirely absent, no sign whatever indicating where it should be, the scrotal raphe being con- tinued without interruption back to the coccyx. In such cases the rectum may also be partially or entirely absent, and the sphinctores ani may or may not be present. 4. The rectum, at some point in the pelvis, more or less distant above its natural outlet, may terminate in a cul-de- sac, and either hang loosely or be attached to some of the surrounding parts. The anus may or may not be wanting. 5. The cavity of the rectum may be interrupted at a variable distance above a well-formed anus by a thick or thin membranous septum projecting into it like a dia- phragm. Sometimes there are two or more of such mem- branous septa. These may form complete or incomplete partitions (as they are perforated or not, or do or do not reach fully to the opposite side) between the various sections of the rectum. Where there are two complete septa, the part between them remains narrow and undistended, like a cord. Where the septa are incomplete, the calibre of the part of the rectum lying between them may attain the normal size. With the exception of these septa the canal is usually perfectly natural. Case 40. Complete closure of the rectum. Lannelongue (Observation I, Microcephalie et Hydrocephalie), (Bulletins et Memoires de la Societe de Cliirurgie, 1884). CONGENITAL CONSTIPATION 389 January 11th, 1884, there is brought to us to the hospital a neAV-born child, five days old. . . . The father of the child is twenty-two years of age, small and rather puny in appear- ance ; he claims never to have had syphilis ; he is in good health ; he has a father and a sister living, both enjoying good health ; his father had been rachitic. The mother of the child is eighteen years old, and is rather sickly ; had typhoid fever at the age of twelve. One of her sisters, it was said, had inverted viscera, the heart being to the right. Besides, she has two phalanges missing on the right hand. The Infant. — He is very vivacious ; he has had no stool since his birth. Furthermore, he is microcephalic. . . . Examination of the anal region sliows that the anus is well formed, and that the anal portion of the rectum has a little over three (3) centimetres in length ; I could introduce the finger, although a little difficulty was experienced ; but, leaving the fin- ger in the infundibulum I felt no sort of impulse, desjDite the efforts and the cries of the child. It was justifiable, therefore, to conclude therefrom that, in a measure, the terminal portion of the rectum was wanting. The distance between the ischii was normal. An artificial anus was made after the method of Littre. An incision is made with the bistoury in the region of the left iliac fossa ; the skin and subjacent muscular layers are divided, and we come upon the small intestines which come up and out through the opening made ; they are pushed back, the large bowel is seized, and fixed with numerous sutures to each lip of the wound. It is incised; but very little matter escapes. A dressing of boracic acid is applied. *********** The child grows weaker and weaker, and on January 16, at 4 A.M., it expired. It had lived ten days. January 17 : Post-mortem examination. Abdominal cavity opened. The peritoneum shows plainly traces of peritonitis ; there are bands of false membrane causing adliesions between various 390 CONSTIPATION IN INFANTS AND CHILDREN loops of intestine, and there is a manifest redness of the intesti- nal structure. No effusion of ftecal matter into the peritoneal cavity. The artificial anus had been made in the sigmoid flexure, and its borders were adherent to the abdominal integument. Immediately below this anus, the flexure pursues its course to the level of the sacro-iliac symphysis; here, this part of the intestine is dilated, and there succeeds to it rather bruskly a round, cylindrical rectum, whose dimensions are not greater than those of an ordinary penholder. The rectum follows its ordinary course into the concavity of the sacrum without in- creasing in size, and, arrived at the coccyx, it continues on with the anal section of the gut. The last portion is about three (3) centimetres in length, and has a calibre superior to that of the other portions of the rectum. Thus the rectum between the sigmoid flexure and the anal section presents a contraction so great that, if flattened down, its calibre is less than one (1) centimetre ; it has the form of a solid cord. *********** Opening the sigmoid flexure above the rectum down to the dilated portion, we are struck by the fact that at the point where the rectum so bruskly succeeds to it, the cavity is im- permeable. In a word, the sigmoid flexure terminates in a cul-de-sac, and from this cul-de-sac, without communicating with it, the rectal cord starts. Likewise below, the anal sec- tion of the bowel is separated from the rectum by a complete partition, which we could not force during life, even after con- siderable manipulation with a stylet and with a female sound. After death we vainly injected liquids ; we could not pass the inferior partition ; we now broke the valvule with a stylet, which then passed readily into the rectum up to the ampulla of the sigmoid flexure ; there the stylet pushes forward a thin mucous membrane which forms a horizontal and convex plane, from the side of the sigmoid flexure, without presenting the slightest orifice. For greater precision, we injected fluid into the rectum ; it elevated the mucous membrane, but it did not penetrate into the sigmoid flexure. There existed, therefore, CONGENITAL CONSTIPATION 391 in this part of the bowel two distinct and perfect diaphragms, the one situated between the sigmoid flexure and the rectum, and the other between the anal and the pelvic portions of the rectum. The lowest diaphragm is located three and a half (3i) centimetres from the anus ; the highest is eleven (11) centi- metres from the anus, or seven and a half (7i) centimetres from the lower diaphragm. Between these two partitions the intestine could not become distended by the meconium, for the reason that no meconium could pass into it ; and although it looks like a solid cord, it is nevertheless a canal lined with mucous membrane. This ex- plains also why, during life, the finger placed in the rectum felt no shock or impulse ; the meconium did not get there. 6. The anus being normal, the rectum for a greater or lesser distance above it may degenerate into a solid mass resembling a cord ; or this degeneration may be confined to its superior portion only, the part reassuming its cylin- drical shape again as it approaches the anus, forming, as it were, a pouch at its inferior extremity. 7. The rectum may be obliterated throughout its whole extent by a thickening of its coats, its walls being approxi- mated and firmly adherent, as if they were glued together'; or this obliteration may take place at one or two points only in the course of the rectum, the canal at these places appearing as if tied together with a tape, the anus and intervening space being natural. 8. The rectum may be present in its proper cylindrical form, whilst its cavity may be blocked up with a substance of cellulo-fibrous character ; an anus may be present or may be altogether wanting. 9. The rectum may terminate in the bladder or in the urethra, in the vagina or in the uterus, or in a cloaca in the perineum with the urethra and the vagina. In these 392 CONSTIPATION IN INFANTS AND CHILDREN cases there is generally no sign of an anus ; yet sometimes, though rarely, it does exist, and permits the introduction of a probe to the extent of four lines. 10. The rectum may terminate in the sacral region by an abnormal anus ; it may be prolonged in the form of a fistulous sinus and terminate by an abnormal opening at different points in the perineum, at the glans penis, labia pudendi, etc. The normal anus is generally absent. 11. The rectum may be altogether wanting, and its place taken by a fatty cellular tissue. In these instances the colon ends in a cul-de-sac, with or without a ligamen- tous appendage in continuation. No normal anus exists, but sometimes an abnormal one does. SYNOPTIC TABLE 1. Preternatural narrowing. 2. Occlusion by a thin membrane. 3. Occlusion by a thick, hard mem- brane. 4. Partial or complete absence. 5. Abnormal. The Congeni- tal jMalfor- mations of THE Anus. Atresia orificii ani. The Congeni- tal Malfor- mations OF the Rectum. Occlusion of the rectum. Obliteration of the rectum. Preter n atural termination of the rec- tum. Absence of the rectum. 1^: By one membranous septum. By two or more membranous septa. By an agglutination of its parietes. By the puckering of its parietes. By thickening and induration of its parietes. In a cul-de-sac. lu the bladder. In the urethra. In the vagina. In a cloaca in the perineum with the urethra and the vagina. In the ano-perineal region at differ- ent points. In the sacral region. Partial. Complete.! 1 Cases illustrative of these deformities are given in extenso by Boden- hammer in the work quoted, and numerous others have since been reported. CONGENITAL CONSTIPATION 393 B. The Colon may be the seat of the difficulty. This may be in the form of a malformation of the colon, of a malplacement thereof, or of an obstruction in any part thereof. 1. Malformations, (a) A part of the large hoivel may he luanting. — The rectum and anus may be wanting, as already stated.^ The colon may be absent in its entirety. For illustrative cases, see Bodenhammer, The Congenital Malformations of the Rectum and Anus. (b) The colon, or any section thereof, may he rudimentary. Case 41. Charles Atldn, F.R.C.S. (Lancet, London, 1885, 1, 203). A male infant two days old was brought to the mfirmary, not having passed any motion since its birth. On examination, a small depression was found at the usual situation of the anus, but it would not admit even a small probe. The abdomen was distended, hot, redder than normal. . . . Mr. Atkin explored the iscliio-rectal region, but failed to meet with any bowel, so an oblique incision was made above and parallel to Poupart's ligament, on the left side ; not finding the colon, a piece of small intestine was stitched and opened in the usual manner. Meconium and flatus came freely from the wound. The child was evidently eased 'and took some milk. . . . After a quiet night, during which the temperature was never elevated, it be- gan to sink, and died during the evening of the following day. At the autopsy, the whole colon and rectum were found to be rudimentary, being about the diameter of an ordinary quill ; at first sight the tube seemed to be a solid cord, and it was not till after the removal of the whole alimentary canal that it was found that firm meconium could be pressed along with the aid of considerable force. The caecum and vermiform appendix were differentiated from the main canal, but corresponded in degree of development. ^ In addition to cases quoted by Bodenhamnaer, see case of Hurd, Boston Medical and Surgical Journal, 1888. 394 CONSTIPATION IN INFANTS AND CHILDREN (c) It may he abnormally contracted. Case 42. Arthur H. Dodd (Lancet, London, 1892, 1, 1299). In this case unusual straining at stool was the earliest symp- tom which attracted the attention of the nurse, but the infant, notwithstanding, thrived noticeably during the first three weeks. At first there were one or two actions of the bowel each day, but very shortly only every other day. About the end of the third week sickness commenced, occurring from five to ten minutes after taking the breast, and at that time only, which was then thought probably due to too frequent suckling. This symptom, however, increased in severity, the amount re- jected at first being only slight; but in a few days from its commencement, the mother thought the whole meal, or nearly so, was returned. I should mention that the character of the sickness was peculiar, the vomited matter not only rolling over the edges of the mouth, but "shooting out" (if I may use the expression) beyond the mother's lap into the room. There was evidently a great deal of pain, the child lying curled up, with the thighs flexed tightly against the abdomen, the feet crossed, and crying at very short intervals night and day. At the fifth week there was a cessation of all symptoms for about seven days, but the sickness, constipation, and pain returned. Throughout, there was never any distention of the abdomen, but double inguinal hernia was produced at a later stage, as a result of the perpetual crying and straining. At the seventh week Dr. E. G. Whittle saw the case with me, and chloroform was administered, but nothing was revealed by the examination. No localized enlargement, tumor, or anything could be detected, and we came to the conclusion that there was some congenital deformity existing in the bowel and thought that no operation was justifiable. Constipation increased, . . . the child gradually sinkinar from exhaustion at the end of the twelfth week. The necropsy . . . revealed congenital contraction of the ascending and transverse colon, which was throughout but little larger than an ordinary lead pencil. The head of the caecum was normal; the vermiform appendix was about two and a half inches in length; the descending colon, sigmoid CONGENITAL CONSTIPATION 395 flexure, and rectum were distended, but normal, with the ex- ception of partial contractions, of an annular character, of the sigmoid flexure. The small intestine was abnormally nar- rowed ; the ileum, for a few inches before its junction with the CcBCum, was very much contracted ; the stomach was pecu- liar in shape, resembling an hour-glass contraction near the cardiac end. All the other organs were normal. Congenital Contraction of the Ascending and Transverse Colon. An- nular Contraction of the Sigmoid Flexure. 2. Obstruction. Case 43. Gould (Lancet, London, 1882). A child aged three days suffered from the usual symptoms of intestinal obstruction. The belly was opened above Pou- part's ligament on the left side. A coil of distended small intestine presented, and as no distended large intestine could be found, it was carefully stitched to the edges of the incision and opened. A large amount of meconium escaped. . . . The child died twenty-one hours afterward. At the autopsy there was no evidence of peritonitis. The caecum, the lower four inches of the ileum, and the first four inches of the colon were filled with a firm whitish plug of inspissated mucus of the con- 396 CONSTIPATION IN INFANTS AND CHILDREN sistence of cheese, which was firmly applied but not adherent to the mucous membrane. Beyond this, the colon and rectum Avere empty and contracted to the size of a clay pipe stem. Above it the small intestines were distended with meconium and gas. It was pointed out that there was no fault in devel- opment, but obstruction from a plug. Case 44. Congenital occlusion of the colon at the ileo-ccecal valve. Weiland (Medical News, January 11, 1896). On October 26, 1895, at 2 p.m., Mrs. Wr., primipara, aged thirty-four years, of Philadelphia, gave birth at full term to a boy of apparently perfect development. Nothing unusual was observed in the infant until October 27 at 1 a.m., when the child began to vomit a darkish fluid which left only a light- colored stain on the clothing. As the child had been given soine tea of a similar color, it was supposed to be that ; at any rate, no pathognomonic odor could be detected. This vomiting occurred on that day whenever the child was given some nourish- ment. As towards evening the bowels had not moved, in spite of a little piece of soap that had been put into the rectum, an injection of lukewarm water with a little soap was given, which returned immediately and brought small cylindrical masses of white mucus about 5 mm. in diameter. This, of course, aroused suspicion at once ; but the next morning, conclusive evidence of an internal pathological condition was furnished by the vomited matter, which now was distinctly faecal in odor, and had the appearance of meconium. As the first thought was that of intussusception, a soft rubber catheter was introduced into the rectum, which could be pushed up about eight inches. Then the nates of the child, who was already very weak, Avere raised, and plain lukewarm water was injected with a Davidson syringe. As the injection returned at once, the anus was gently compressed, and about two ounces of water were again injected. This procedure increased the vomiting of fcecal matter very much, and so was stopped at once ; but the vomiting continued, respiration became embarrassed, and soon the child died, about forty-eight hours after birth. The post-mortem examination showed the following condition of the intestinal tract : the CONGENITAL CONSTIPATION 397 small intestine showed great vascular injection, and was much distended with gas, especially near the ileo-c£Ecal valve. Here the diameter of this viscus was about 18 mm., the same as that of the caput ctecum, with which the small intestine was con- tinuous, as tlie lower fold of the ileo-csecal valve was absent, or rather ver}^ little developed. The upper part, however, of this valve, the ileo-colic fold, was developed too much ; for it stretched across the whole lumen of the bowel and formed a complete septum between the colon on the one side, and the caecum, with the vermiform appendix and small intestine, on the other side. There was not the slightest chance for a communication between these two parts. Below this anomalous diaphragm, the caecum and small intestine showed well-developed villi, and the entire mucous membrane was stained brown with biliary pigment, and showed a small amount of meconium. Above the abnormal septum, the large intestine was very much contracted, having a diameter of only 5 mm. It had also no ascending part, but the transverse colon turned back at once to the posterior aspect of the abdominal cavity, and ran transversely as far as the usual position of the splenic flexure, where the descending colon com- menced. The whole colon and rectum, about ten inches in length, contained only soft white mucus, and not the slightest trace of meconium. Its surface looked white compared with the color of the small intestine, and its walls were thin, having apparently been arrested in its development. 3. Malplacement. Case 45. A. J acobi (American Journal of Obstetrics, 1869). Twelve to fourteen hours after birth no meconium. . . . On the third day, the left iliac region in front, and a little above the anterior superior spine, appeared to fill up and yield a somewhat duller percussion sound. . . . Operation made in this spot ; it resulted in our finding a pouch of the descending colon, filled with a large amount of meconium, which was readily discharged through the artificial opening. . . . The patient did well for a short period, but died of peritonitis on the fifth day after the operation. 398 CONSTIPATION IN INFANTS AND CHILDREN Necropsy. — The part of the colon fastened to the abdominal wall was no longer dilated. . . . Besides the consequences of peritoneal inflammation, nothing was abnormal in the immedi- ate neighborhood. All the parts above the incision, and all the other viscera, were not diseased. Below the point of incision lay the colon turned three times upon itself; three flexures covering each other in such a manner that the subjacent one was always about half an inch longer than the one above it. The lowest of the three, crowded down into the pelvis, was entirely compressed, contracted, and contained nothing but a little hardened mucus ; the middle flexure contained the same mucus, and a small amount of meconium ; the upper one was filled with meconium as far as the contracted lumen of the bowel would allow, and its outer left portion was the one which had appeared dilated by the meconium crowding down from above. The inferior flexure reached beyond the median line, stretched upward to nearly the anterior superior spine of the right side, and from there the intestine turned back in an acute angle into the pelvic cavity, doubled upon itself, and reached the median line on the right side of the empty bladder, and terminated as the rectum in the normal place. When the bowel was removed, it measured, from the point of incision in the left hypogastrium to the anus, nearly fourteen inches. The ascend- ing colon was of normal length ; the transverse colon was not in the normal position, but stretched from the right hypogas- trium to the left anterior superior spine, diagonally, in an almost straight line, forming an acute angle with the uppermost curva- ture we have described, and giving rise to the pouch we found dilated before and during the operation. C. The malformation leading to the constipation or obstruction may be located in the small intestines. 1. The small intestine may he almost entirely oUiterated. Case 46. Congenital obliteration of the small intestine. John Thompson (Edinburgh Medical Journal, 1892, Vol. 2). Infant, two and one-half days old, seen on November 12 CONGENITAL CONSTIPATION 399 (1890), on account of complete obstruction and constant vomit- ing, along with my friend, Dr. Home Ross. *********** Present Condition. — The child is well developed, and of natural size. The skin is bright red with a strong orange tint. The conjunctiva are only slightly yellow. The lips, the vertex of the scalp, the palms and soles, and the neighborhood of the anus are all markedly cyanosed, and there is a bluish tinge over some other parts of the body. The tongue and gums are quite free from this. The child cries constantly, as if from hunger. No external malformation. . . . Abdomen not distended, but its walls are very tense. On percussion, a tympanitic note is got over the region of the stomach, but all over the lower part of the belly the note is absolutely dull. The liver and spleen cannot be felt. The anus seems small, but admits the little finger without much difficulty, and is felt to contain a few soft rounded masses. These, when removed by an enema, are found to amount to rather more than a teaspoonful in bulk. The matter is absolutely without odor, and of a whitish color, with no tinge of green or yellow. November 20, child died at 7 A.M., aged ten days and four hours. On opening the abdomen, a large tumor of purj^lish- red color is found to occupy the greater part of the left half of its cavity. This is found to be the distended portion of the gut just above the seat of the obliteration. The rest of the bowel is found to be contracted to its fullest extent, and is of a pale yellowish color. Intestines. — At the very commencement of the duodenum the gut becomes enormously dilated. The dilated portion measures ten inches in length, and from one to one and one-half inches in diameter, and is of a dark purplish-brown color. It comprises the whole of the duodenum, and probably also a few inches of the jejunum. Its lower extremity is an abruptly rounded end ; it is perfectly closed, and there is a gap between it and the next portion of bowel. The mesentery belonging to it also comes to an abrupt end, there being a deep fissure between it and that of the succeeding pieces of intestine. The blood-vessels in the 400 C0KSTIPATI0I7 IN INFANTS AND CHILDREN mesentery are very unusually large. When the distended duo- denum is opened, it is found to be full of a turbid yellowish- brown fluid, — evidently the food swallowed mixed with bile and other secretions. A short distance from the dilated por- tion of the bowel is a small bit of gut one and one-fourth inches in length, and one-sixth inch in diameter. It is blind at both ends (which are rounded), and is fixed in the shape of a horse- shoe by a little tongue-like flap of mesentery. When the mesentery is followed to the right, its free margin is found to be thickened in places by what appears to be frag- mentary remains of obliterated bowel, and it is prolonged into a peaked flap lying horizontally. From the point of this flap a small rounded fibrous band passes in among the neighboring coils of intestine, and after encircling the mesenteric attach- ment of a large portion of the bowel is fixed by a fan-shaped end into the middle of the upper surface of the mesentery of a coil of jejunum, about seven or eight inches below the lowest point of obliteration. The fibrous band is one inch in length ; it is very dense in texture, and resembles fine silkworm gut in size and appearance. The small intestine becomes XDcrvious again about two and one-half inches below the horseshoe-shaped fragment. During the rest of its course it varies in diameter from one-eighth to one-sixth inch. In one or two situations the lumen is seen to be occupied by small masses of green matter; elsewhere it seems quite empty. The large intestine is similarly contracted, measuring only about one-fourth inch in diameter, and is in a similarly empty state. Case 47. Dr. Greig (Canadian Practitioner, 1892). Infant lived four days. . . . The stomach and duodenmn were healtliy and normally developed. The rest of the small and large intestines were abnormal, and had no connection with the duodenum. Extending downward from the stomach, there were about two feet of healthy bowel ending in a cul-de-sac. Extending upward from the rectum, there were about three inches of CONGENITAL CONSTIPATION 401 fibrous cord. It was tlie size of a lead pencil, firm to the touch, and on section pervious. Two inches from the upper end it dilated, contained fffical matter, and ended in a point. There was no connection between the two sections of the bowel. Congenital Oblitekation of Small Lxtestjnes. Case 46. 2. There may he a gap in the small intestines. Case 48. Imperforate ileum. J. Bland Sutton (American Journal of the Medical Sciences, 1889). In June, 1889, my friend, Dr. Maxwell, asked me to see a 402 CONSTIPATION IN INFANTS AND CHILDREN baby forty-eight hours old, concerning which he furnished the following history : The abdomen was found distended shortly after birth, and the baby commenced to vomit its food. On examining the anus, the parts were found quite normal, and a catheter could be passed readily into the bowel for many inches. Nothing but mucus passed by the anus. It was clear that we had not to deal either with imperforate anus, rectum, or pharynx, as the infant could swallow easily, and as it retained milk for a time imperforate duodenum was excluded. I therefore came to the conclusion that we had to deal with an imperforate ileum. At the request of the parents I explored the abdomen, and found the ileum imperforate at a spot about eighteen inches from the ileo-csecal valve. The distal end of the ileum was somewhat shrunken, and separated from the proximal end by a gap an inch across. The upper cul-de-sac was dilated with meconium, and congested ; this was removed, and the end of the gut stitched to the abdominal wound. Meconium and flatus passed freely, the child rallied and took food, and the case promised to go Avell, but about six hours later it suddenly expired. Case 49. (British Medical Journal, 1886, Vol. 2, 295.) Mr. William Thomas exhibited the stomach and intestines of an infant five days old that had been operated on for obstruc- tion. The stomach was of normal size ; the duodenum became gradually enlarged as it reached its termination ; the jejunum was very large, and formed dilated coils which had distended the abdomen. It had been opened twenty-two inches from the pylorus for the relief of the obstruction, and ten inches further it terminated in a blind extremity. The small intestine recom- menced almost immediately between the layers of the mesen- tery, being about the size of an ordinary pencil ; it formed several coils, and extending for thirty-six inches, terminated in a well-formed caecum, from which a perfect, though contracted, colon could be traced to the anus. The various parts of the intestine were so firmly matted together by well-organized bands of lymph, the result of previous intra-uterine peritonitis, that the relation of the parts could not be made out until the intestine was removed from the abdomen. CONGENITAL CONSTIPATION 403 The child was somewhat relieved by the operation, and lived for about eighteen hours after it. 3. There may he no connection between the large and small intestines. Case 50. J. C. Oliver (Cincinnati Lancet and Clinic, August 15, 1891). A male child, born in the service of Dr. Allen, developed symptoms of intestinal obstruction and died four days after birth. Autopsy. — The small intestine was distended so as to occupy the entire abdominal cavity. This bulged out as soon as the abdomen was opened. Upon tracing the small intestine downward from the stomach, it appeared normal until the lower end of the ileum was reached, and here we perceived that it ended in a blind pouch. Lying immediately below this was the free extremity of the large intestine, opening into the peritoneal cavity. There was absolutely no connection between the intestines at a point corresponding to the ileo-csecal valve. Case 51. Carini (Internationale klinische Rundschau, Wien, 1890). A female child four days old was brought to the hospital for outdoor treatment. The child suffered from intestinal ob- struction, having had no evacuation since its birth. Tf^ ^ ^ Tf: Tfi ^ 1* V ^ The small intestines end in two blind pouches, consisting of thin loops having the macroscopic form of the intestine ; they look like two diverticula of the small bowel, and do not com- municate with the large intestine. A further loop is connected with the umbilicus ; it represents a Meckel's diverticulum. The large bowel is free from faeces. It begins in a blind loop, the calibre of which progressively increases until it reaches the normal diameter. The rectum, of normal length, is imper- meable at the upper half ; the lower half is dilated and of a dark-red color, due to numerous ecchymoses into the mucous membrane. A slight laceration at the anal extremity. 404 CONSTIPATION IN INFANTS AND CHILDREN 4. The ivJiole digestive tract from the stomach down may he disconnected. Case 52. Total occlusion of the ccecum. Rudimentary pan- creas. Absence of duodenum. Jejunum ending in a cul-de-sac. No connection between stomach and small intestines and intes- tines and gall bladder. Ill-developed colon in new-born infant. O. A. Fliessburg (Northwestern Lancet, 1891). The child was in all respects as large as a foetus of nine lunar months, seemingly well developed, and cried lustily soon after birth. . . . The next day everything seemed all right, but the nurse told me the baby had not yet had a movement. I inspected the child and found nothing out of the way, except that it had a poorly developed mouth and could not nurse. . . . It lived one hundred and eighteen hours before it died. At the autopsy, eighteen hours after death, the following (3onditions were found. . . . On opening the abdominal cav- ity, I found at once the place of obstruction ; it is situated at what I think to be the cpecum, or it may be the ileum ; the intestines were very strongly matted and glued together into a pyramidal coil. There was no connection to be found between the upper viscera and the smaller intestines. . . . The condition of the intestines is already described in the title. 5. TJiere may he a congenital stricture located in any one of the sections of the small intestine. Case 53. Congenital stricture of the duodenum. J. H. Emerson (Archives of Pcediatrics, 1890). Infant born April 24, 1890, after normal labor. It weighed eight and one-half pounds and appeared well until thirty hours old, when it spat up one-half ounce or more of dark blood mixed with mucus. . . . There was a dark, tarry stool. The child evinced no desire for food ; there was no evidence of sufPering except when raising blood, which caused some gagging. There was no cougli,_no fever no disturbance of respiration, nothing found on physical CONGENITAL COXSTIPATION" 405 examination of the fauces, etc. Another stool contained only meconium, no blood. Post-mortem examination showed the stomach markedly dilated, the pyloric orifice two centimetres in diameter; the duodenum markedly distended, but terminating abruptly just above the orifice of the common bile duct. Fluid could not be forced from the stomach below this point, nor could air be forced upward from the intestine to the stomach. Case 54. Stricture of the duodenum. Grimsdale (Liver- pool Medico-Chirurgical Journal, 1892). A few months ago a midwife told me that she was expecting shortly to attend a woman in her confinement who had pre- viously had five children ; one of these was still born, and the remaining four had all died on the third day, . . . and it was supposed that they had died because the valves of the heart had not closed. On August the 6th the child was born, and I accordingly went to see it. The child was a well-formed boy and looked healthy and well nourished. I examined him and could find nothing whatever wrong. . . . The child had passed water, and the bowels had acted. All seemed to go well for the first two days, but on the third day the child took a slight convulsion and vomited a little. *********** I examined the abdomen again and again, and found it quite flaccid, and apparently no tenderness over it anywhere. The bowels were acting frequently, the motions being still meco- nium. The child had only vomited once, and then only slight, according to the account of the relations. There was therefore nothing on which to diagnose obstruction. ... On the fourth morning I again saw the child, and found that it had convul- sions. It was in almost exactly the same state as on the pre- vious evening, and I was as much in the dark as ever. I ought to mention that the child was taking the breast regularly. On the evening of the fourth day I had a message to say that the child had another convulsion. I went down at once to see the child and found it dead. There was a large quantity of black 406 CONSTIPATION IN INFANTS AND CHILDREN vomited matter, Avliich looked like milk mixed with meconium or semi-digested blood. The next day I made a post-mortem. The stomach and duodenum were much dilated ; the rest of the intestines were quite small and cord-like. I removed the stomacli and intestines, and found that there was an occlusion of the gut situated about two inches from the pyloric end of the stomach, just above the opening of the bile duct. This entirely obliterated the intestine, the duodenum terminating in a cul- de-sac. 1 6. The obstruction may he due to a memhranoiis clia- jjhragm j^rojecting into the lumen of the howel at one or more points. Case 55. F. Charlewood Turner (Transactions Pathologi- cal Society, London, 1887). A female infant died on the fourth day. About the middle of the jejunum a portion of the canal, about an inch in length, was found shut off from the parts above and below by mem- branous diaphragms. It contains a small quantity of mucous secretion which cannot be pushed past either boundary. The bowel above is greatly dilated ; that below is contracted. Case 56. Grawitz (Virchow's Archiv, Vol. 682). Child died eight days after birth. The jejunum is dilated to almost colossal dimensions (see cut) by the accumulation of masses of meconium and gases. It extends to the point a, a point of constriction, and which presents the appearance as if the adjoining and narrower section of the lU (ileum) were a strange body soldered on to the larger ; nevertheless the walls are continuous, and the constriction furrow at a denotes the point at which a membranous diaphragm projects into the lumen of the tube, and cuts off to a considerable extent the free inter- 1 See also Rosenkranz, Max, Ein Fall angeborener Stenosirung des Dunii- darms u. Dickdarmes nebst defekt einer Niere, Konigsberg in Prussia, 1890. Index Medicus, 1890. 2 Dr. Paul Grawitz, Ueber den Bildungsmechanisnius eines grossen Dick- darmdivertickels. CONGENITAL CONSTIPATION 407 communication between the parts, the opening remaining not being larger than a lentil. This membrane, which shows through on the dry preparation, is exactly like the diaphragm of a microscope. Through its round central opening, meconium J, Jejunum, a, Point of junction of jejunum and ileum, — membranous diaphragm with a perforation at this point. 11^, First 111 section of ileum, h, Point where second complete membranous dia- phragm is found. IV^, Further section of ileum. a masses passed into the following section, the and effected here also a dilatation to more than three times the normal calibre, as shown by IL"^. This second section reaches to the point h, at which another constriction furrow presents. At this point another membranous diaphragm projects into the canal, and cuts off completely all communication between the parts above and those below. The rest of the small bowels and the large gut (which does not appear in the figure) are empty and very narrow, especially in compari- son with the jejunum. 7. lliere may he a stricture at one point and an obstruct- ing diaphragm at another. Case 57. Demme (Wiener mediz. Blaetter, 1884). Girl four months old. It was not till the fourth day after her birth that she had an evacuation of meconium of brownish- gray color and of mortar-like consistence. From this time on the child had an evacuation only every two or three days, later on only four or five days. May 2, 1882, at the expiration of her third month, a protracted obstruction with progressively increasing meteorism set in. May 9, the seventh day of the obstruction, an icteric discoloration of the skin and conjunctiva 408 CONSTirATION IN INFANTS AND CHILDREN IS noted, and she vomits every ten or fifteen minutes a tliin watery fluid. The infant refuses all nourishment, and will take nothing but one-half to one teaspoonful of ice-water from time to time. With the exception of warm moist abdominal en- velopments, lukewarm baths, and rectal injections, no treatment IS possible. May 10, as on the preceding days, three-fourths of a litre of lukewarm water was injected into the rectum by means of the rectal tube, with funnel and elevated position of buttocks. After the discharge of the water, a great mass of thin faices of grayish color and horribly offensive was evacu- ated with an abundance of flatus. Three hours later the essen- tial symptoms had disappeared. The temperature in the rectum had fallen to 37.4° C. (99° F.) ; the abdomen had become soft; the vomiting was arrested. By the daily administration of small doses of castor oil, a daily evacuation of f^ces was ob- tained up to May 20. Th'e mother having lost her milk, the child was fed with condensed milk properly diluted. May 20, obstruction has again set in with vomiting and persistent and harassing singultus. The treatment employed was large injec- tions of water. May 26, no evacuation to date ; continuous vomiting of faecal matter to-day. The little patient died at 6 P.M., after complete exhaustion of her vital forces. On 0]3ening the abdomen, there was found a superficial agglu- tination of the intestinal loops by thin, yellowish-red fibrous bands. The peritoneal covering of the various sections of the bowels was but moderately injected, and then mainly in the form of little islets. On taking out the bowels, the various sections appeared, as was already seen whilst they were still in situ, rather unequally dilated. The duodenum was dilated to sack-like dimensions, and filled with meconium and gases. In the collapsed jejunum there were found at the borders of the duodenum and of the ileum points of constriction from three to five centimetres in length. Laid open, the tissues at these two points were found tough and cord-like, and the lumen so nar- rowed that only a very thin lead pencil could pass through. The jejunum was furthermore almost completely cut off from the ileum by a crescentic fold of mucous membrane, which pro- COiVGENITAL CONSTIPATION 409 jected like a diaphragm into the lumen of the canal. The cord-like points of constriction, especially the one between the duodenum and the jejunum, were covered with fibrinous exu- dations. The mucous membrane of the duodenum was dis- colored blackish-green, was tumefied and soggy, friable, but nowhere torn. The ileum, caicum, and colon were collapsed and almost empty ; the mucous membrane was pale. Treatment. — The treatment of constipation dependent upon malformations, where treatment is possible, is en- tirely surgical, and the details thereof can be found in extenso in the work of Bodenhammer referred to, in the works on the diseases of the rectum, and in the various treatises on surgery. Here I Would only call attention to these two points : {a) Narrowing of the orificium ani can be very properly treated by dilatation. (b) In a case in which the rectum was obstructed by two membranous diaphragms, Lannelongue succeeded in perforating the upper through the artificial anus which he had established, and cut out the lower one by an incision from the exterior and the natural passage for the faeces was thus re-established.^ Case 58. Lannelongue (Observation II.). May 24, 1882, there was brought to the hospital Trousseau a new-born infant of the male sex, fifty-two hours old at the time of the examination. He is the second son of healthy parents, and there is no evidence of any syphilitic antecedents in the parents. The infant is lively, urinated easily, but has not passed any meconium since its birth. It is otherwise Avell formed. Examination of the anal region : nothing particular 1 Lannelongue, Sur une Variete Rare de Malformation Congdnitale de la Region Ano-rectale. Bulletin et Memoires de la Societe de Chirurgie, 1884. Virchow und Ilirsch, Jahresberichte, 1884. 410 CONSTIPATION IN INFANTS AND CHILDREN is seen ; the anus and its folds are normal ; the finger introduced therein passes into an infundibulum two to three centimetres in depth. It is rather diificult to introduce the finger, and when the infant cries or weeps, no sort of impulse is felt. A careful examination excludes the existence of a rectal ampulla. The belly is distended ; the abdominal parietes are not cedema- tous; the intestinal loops cannot be seen outlined upon the abdominal wall. The infant is operated upon after the method of Littre ; the gut is found beneath loops of small intestine. It is stitched to the abdominal parietes ; it is opened, and a great quantity of fseces or meconium flow out. The intervention has been a happy one ; a good nurse is secured, and the child is brought to us at first every day, then every second or third day. The 15th of June : the opening in the abdominal parietes began to be the seat of a retraction process ; there is a simple erythema all around it, provoked by contact with intestinal matters. June 18 : the artificial anus is well constituted ; the cutane- ous orifice is rounded, and permits of the passage of the finger. At the bottom there is felt a slight projection of mucous mem- brane. I took a uterine sound and directed it to the lower end of the opening. It was promptly arrested at about two to three centimetres from the cutaneous orifice ; there was an obstacle which looked to me as if it were the termination of the intestine. As I was endeavoring to discover the distance which separated it from the anus, which was really rather great, it seemed to me that the resistance I had encountered yielded, although I made but very moderate pressure. A little stronger effort, and the sound entered the pelvic cavity ; it was too short to reach the anus, so I took one of Chassaignac's long curved trocars, and with a great deal of care introduced it by its blunt end. It stood out rather prominently at the summit of the infundibulum of the anus, and I could feel it with the finger introduced into the infundibulum from below ; a very slight thickness separated the point of the trocar from the summit of the infundibulum ; it would have been possible by proceeding with some violence to pass this separation. CONGENITAL CONSTIPATION 411 I concluded, nevertheless, to proceed otherwise. A posterior incision was made, beginning at the anus, down the median line, toward the point of the coccyx, about one and one-half centimetres in length; the skin, the underlying tissue, were successively incised, and finally the obstructing membrane itself was cut on the instrument. A drainage tube of large calibre, reaching from the natural to the artificial anus, was inserted, and allowed to remain. Two sutures reunited the perineal incision. It was also advised that an injection of a weak solution of boracic acid be made daily through the tube so as to cleanse it. June 19: the child is in excellent health; he has passed fgecal matter through the cavity of the tube. Two days later, June 21, the drainage tube was taken out to be cleansed; a rather large sound is introduced into the rectum, and passes readily beyond the lower obstacle. The drainage tube is replaced ; the opening of the artificial anus will barely admit the tip of the finger. June 23 : sutures taken out ; no inflammatory engorge- ment ; every day, f tecal matter passes through the large tube. June 26 : drainage tube withdrawn and cleansed ; rectal sounds of graduated calibre are passed ; the drainage tube is replaced, and allowed to remain to the 29th. At this date large quanti- ties of faecal matter passed out through the artificial anus. The infant is seen again July 2 ; the mother is advised to pass daily the rectal sounds through the normal anus. An enteritis with frequent and abundant diarrhoeal dis- charges sets in, and since the night before the child looks bad, very much exhausted. Since then I have not seen our little patient, and I have all reason to believe that it has succumbed. Chronic Constipation. — Certain congenital malforma- tions (Shelf, perforated or incomplete diaphragm, etc.) may be the cause of a chronic constipation that lasts throughout life. It usually manifests itself fiirst at a later period, at a time when the faeces become firm in consist- ence and abundant in quantity. See Part I., Chap. VII., and Part IL, Chaps. III. and V. CHAPTER II ACQUIRED CONSTIPATION I. Acute Constipation The term " acquired constipation " explains itself. It means that this form of constipation is acquired by the little patient through some fault or neglect on the part of the parent or nurse, or as a consequence of some morbid process developed subsequent to its birth, and that, in contradistinction to the form previously considered, it is not due to any inherent vice of anatomical conformation. The acquired constipation of infants presents itself to us in one or other of two forms already named ; viz., I. Acute constipation. II. Chronic constipation. Acute Constipation. Acute constipation has been already defined elsewhere and needs no further elucidation here. It is caused in infants by : Intussusception, volvulus, strangulation through a slit in the omentum. Strangulation by bands. Hernia (inguinal, femoral, or umbilical). Paralysis of the intestine consequent upon traumatic injury of one or more loops. 412 ACQUIRED CONSTIPATION 413 Case 59. In January, 1875, I was called to see Mary B. in consultation with Dr. . The little patient, (bL five years, was in bed, presented an emaciated appearance and a counte- nance expressive of much suffering. She was ill now four days. The history, as given me, was that she had complained of pain in the belly and about the loins, had had considerable fever, vomited frequently, complained of headache, and was thought to have had some delirium at times. For various reasons the physician in attendance had diagnosed the onset of smallpox (the disease was then prevalent) and had prescribed a laxative. This proved ineffective, and a stronger purge was ordered ; this also had no effect. In fact, the child was obstinately con- stipated, despite all the measures taken to produce an evacuation. The vomiting had abated since the third day, though the child took nothing more than a little milk and water, and of this but a teaspoonful or two at a time. Examining the little patient, I found the belly very tender in a limited region about the umbilicus and upward toward the large bowel, and so sensitive was this part that she cried out upon the slightest touch. The thighs were flexed upon the pelvis, and the legs upon the thighs ; upon the slightest attempt to straighten out a lower limb, she cried with pain. The tem- perature was 101° F.; pulse very rapid and feeble. Upon questioning the mother very closely about the onset of the illness (as I failed to recognize any evidence of approaching variola), I learned that on the afternoon of the Sunday pre- vious the child had been sent out to get some beer. In going to the saloon, she stepped upon an iron cellar door, which she had failed to see owing to the snow that covered it, slipj)ed, and fell upon her belly. She complained of some pain on her return home. That evening she vomited rather frequently ; the pain grew much worse as the night progressed, but abated considerably toward morning. My diagnosis was traumatic injury of some portion of the intestinal tract, and most probably of a portion of the small bowels. The efforts at purgation were at once suspended. Opiates 414 CONSTIPATION IN INFANTS AND CHILDREN were prescribed; hot fomentations to the abdomen and small rectal injections of very warm water were ordered. The child continued to grow worse, and died on the eighth day of its illness. I was very anxious for a post-mortem view, and by means of a ruse-de-guerre I succeeded in obtaining permission to open the belly in the presence of a relative. Post-mortem twenty- eight hours after death. Body almost frozen. The parietal peritoneum presented nothing abnormal ; cutting this, and turning it aside, we found right before our eyes a loop of the small bowel that presented a mortified appearance. It was of a dark rusty color with streaks of green here and there. Only this single loop was affected ; the other parts of the intestinal tract and other abdominal organs were apparently healthy. Acute diseases of the small bowels (duodenitis, enteritis). Acute diseases of the large bowel (typhlitis, appendi- citis). Acute diseases of the liver. Inflammation of the peritoneum. Acute diseases of the brain and spinal cord. The modus operandi of these various factors has been set forth in Part I. Acute constipation may be caused furthermore by : Foreign substances swallowed in sufficient quantity to obstruct the lumen of the bowl. Children usually swallow the stones of fruits (as of cherries, plums, etc.), or the seeds thereof (as of grapes), with the fruit itself, and if these be in any quantity they will pack together, and obstruct the passage through the bowel. Occasionally food or the parenchymatous portion of the fruit swallowed msufficiently masticated, in chunks, may cause the obstruction. ACQUIRED CONSTIPATION 415 Case 60. A. H. Watkins (Lancet, London, 1885, Vol. I., p. 457). A boy ten years of age was brought to me by his mother, saying he was suffering from constipation of four days' dura- tion. As the patient walked with difficulty, and complained of a great deal of pain about the anal region, I made a local examination, and found the anus loose and flabby, and occupied by a hard, dense mass of fig pips, of which a good number were adherent to the buttocks. Finding it impossible to introduce an enema tube, I proceeded to remove the mass by scraping away with the fingers, the relaxed condition of the anus readily admitting two fingers, though the acute pain that the patient suffered made it necessary to administer chloroform. I re- moved in this way half a pound (weighed) of fig pips, besides many which were washed out afterwards by an enema. The whole bowel for several inches seemed quite paralyzed by the distention to which it had been subjected. On the following day the patient seemed quite comfortable, and the bowels had acted. As I have heard nothing of him since, I presume he is well. The following case repoi-ted by Townsend (Annals of Gyncecology and Poediatry, March, 1897), is of the greatest interest, as it seems to show that foreign bodies may penetrate through the abdominal parietes into the abdominal cavity and cause acute obstruction. This is really not to be wondered at, when we remember how much children crawl around on the floor and on the ground among the j)oorer and middle classes, and how frequently needles, pins, etc., are scattered about, and how very often the flooring is of the roughest boards. Case 61. For several months past the child had attacks of crying as if in pain, and the mother, supposing them due to colic, paid but little atten- tion to them. Suddenly the symptoms grew more urgent, the abdomen became swollen, incessant vomiting set in, and the now alarmed mother brought the child to a physician, who sent him to the hospital for opera- tion. On examination a tense, painful tumor was noticed just to the left of the umbilicus. From this, in conjunction with the symptoms, a diagnosis of acute intestinal obstruction, due probably to an incarcerated umbilical hernia, was made, and the child was immediately operated upon. On incising over the swelling the knife passed through a dense inflam- matory exudate thrown out into the left rectus muscle ; upon further inci- sion the abdominal cavity was opened, disclosing the inflamed intestine 416 CONSTIPATION IN INFANTS AND CHILDREN adherent for some distance to the abdominal wall. On separating the adhesions a pine splinter, about one inch long, was found — one portion em- bedded in the abdominal wall, and the other protruding into the intestinal canal. . . . Worms. — J. Lewis Smith ^ relates the case of a ghl four years of age in whom acute constipation developed suddenly, and was accompanied by distention of the abdomen and great suffering. This continued nearly one week, when a mass of intertwined worms was expelled with immediate relief. A large gall stone, which will obstruct the ileo-ccecal valve, may be the direct cause of an acute constipation. The diagnosis of acute constipation is rather the diag- nosis of the morbid condition of which it is but one of the symptoms, whether this be some grave pathological pro- cess or some foreign body that can be readily removed. So far as the former is concerned, the differential diag- noses can be found in detail in the various treatises already referred to. As regards the latter, a careful inquiry as to the mode of onset of the attack and the conditions of the child and events jnst preceding it ; a history of the habits of the child, its amusements, its diet and manner of eating, its supervision ; and a careful ex- amination of the rectum, — may, and in great majority of cases w^ill, lead to its recognition. The treatment will be found in the special books upon the various topics and the large general treatises. I would only call attention once more to what I advocated in my article on "Intestinal Obstruction,"^ that in all cases where we may have reason to suspect a sudden 1 Diseases of Children. 2 American Journal of the Medical Sciences, January, 1886. ACQUIRED CONSTIPATION 417 obstruction of the intestinal canal, large massive enemata should be immediately resorted to, for the reason that they have a marked and rapid curative effect, and if they fail we know at once that operative interference is necessary, and that it should be resorted to without delay. CHAPTER III II. CHRONIC CONSTIPATION For the purposes of a clearer understanding and a better comprehension of the therapeutic indications, this cate- gory of our subject is divided into two groups, namely : I. Chronic Constipation, dependent upon an abnormal condition of one or more organs or parts of the body. II. Habitual Constipation, due to functional disturb- ance. Chronic Constipation Chronic constipation may be due to some congenital malformation of_ the intestinal tract, as has already been indicated, or it may be produced by any of the various pathological conditions which give rise to it in the adult, and which have already been enumerated in a previous chapter.^ Case 62. Cancerous growth pressing upon the rectum. Thomas Smith (Transactions Pathological Society, London, Vol. 19). The specimen was removed from a child, aged fourteen months, under Mr. Smith's care at the Children's Hospital. Two months before admission the mother noticed that the child had difficulty in passing the motions, and soon afterward that it strained when passing water, and that occasionally the urine dribbled away. These symptoms increased in severity, 1 See Part I., " Chronic Constipation." 418 CHRONIC CONSTIPATION 419 and the child seemed at times to have pain in the belly. A month ago a hardness and swelling were noticed in the lower part of the abdomen ; they have gradually increased. A month ago retention of urine came on, which was relieved by the catheter. At no time has any blood been seen. . . . The tumor felt during life proved to be a large, malignant growth springing from the recto-vesical pouch, filling the pelvis, and growing vipward into the abdomen behind the bladder, which was greatly elongated, esjDecially about the neck, the fundus lying above the level of the umbilicus. The coats of the bladder were greatly hypertrophied, but otherwise healthy. The tumor was partly solid, but in the upper part were numerous cysts containing a semi-fluid substance. Anal fissure is regarded by Gautier,^ of Switzerla-nd, as a frequent cause of clironic constipation in the new-born. J. Lewis Smith ^ says that it is of rare occurrence then, and in this, taking the term " new-born " in its stricter sense (to a month or six weeks), my own experience fully con- firms him. At a later period, however, in later infancy and early childhood, it is of more frequent occurrence, as was already noted by A. Jacobi,^ and is many times the unsuspected cause of the general fretfulness, of the par- oxysms of crying, of the sleeplessness of the child. Excoriation of the Anus. Case 63. Boy, cet. three and one-half years, stout, rather robust-looking little chap. His mother complains that every evening at six he begins to cry, and continues to do so almost without cessation until twelve midnight. When the pain or crying spell comes on, he will not sit or He quiet. He is continually changing his position. There is, according to ^ Quoted by J. Lewis Smith, Diseases of Children. 2 Diseases of Children. ^ Intestinal Diseases of Infancy and Childhood. 420 CONSTIPATION IN INFANTS AND CHILDREN her statement, nothing abnormal in the stool ; the urine is normal ; there is no fever. He was closely examined, but nothing at all could be found that would account for the crying spells. Persistent inquiry elicited that the boy did not pass his urine well, that it dribbled away, but that in the morning, on arising, he passed a fairly large quantity. It was also learned that the boy was costive, and, finally, it was disclosed that the crying spell coincided with the time when the little fellow was placed on the vessel. Examining now the anus by drawing the nates well apart, I found the sphincter excoriated, sore, inflamed all around, and coated with pus. The excoriations and inflamed condition extended up some distance. Tubercular Peritonitis may cause Chronic Constipation. Case 64. J. Lewis Smith, i Charles, cet. four years, was returned to the New York Foundling Asylum on April 16, 1877, to be treated for tumor albus of the left knee, and for general ill health. His parent- age and early history were unknown. The nurse in the city, to whom he had been entrusted when quite small, stated that he 'had had no sickness when with her except sore eyes, and that about April 1, 1877, the enlargement of the knee was first observed. The head of the boy was large, and the abdomen much distended, but without any decided tenderness on press- ure ; its entire lower part had a purplish color. Percussion over it gave a dull sound except upon and near the epigastrium, Avhere there was some resonance ; umbilicus prominent ; cir- cumference of body over abdomen, twenty-three inches ; pulse 128 ; axillary temperature, 99° F. It was stated that he had no stool without medicine, and that usually one tablespoonfal of castor oil was required to produce it. The urine contained no albumen, and was apparently normal. As the appearance indicated struma, a mixture of cod-liver oil, syrup of the lacto- phosphate of lime, and iron was prescribed to be given three 1 Loc. cit. CHRONIC CONSTIPATION 421 times daily, and directions were given to rub cod-liver oil over the abdomen also three times each day for five minutes each time. Some nodules were felt on pressure u^Don the abdomen, which Avas suspected were enlarged mesenteric glands. From the day on which the friction and kneading of the abdomen were commenced, the stools began to occur on the average about twice daily. The kneading proved the safest as well as the most efficient method of producing defecation. On May 4, the circumference of the trunk over the most prominent part was reduced to twenty-six inches. The records on May 11 state, " Same treatment continued ; has tolerable appetite, but is pallid, and his flesh flabby and soft." From this time he gradually failed, and died April 11, 1878. Autopsy. — Lungs healthy, except a little exudation over the summit of right lung ; bronchial glands cheesy ; numerous tubercles, some of them cheesy, upon the parietal and visceral surface of the peritoneum. Loops of the intestines were united to each other by old adhesions, and the small intestines were generally bound down by bands into a " uniform conglomera- tion " ; mesenteric glands, enlarged and cheesy ; a large ulcer upon the surface of the rectum, and numerous small, round ulcers upon the surface of small and large intestines apparently occupying the site of the solitary follicles. Chronic hydrocephalus is always accompanied by a chronic form of constipation. Rachitis induces chronic constipation (debility of the muscular coat). As to the diagnosis and treatment, what has been said in the preceding chapters applies here also. This may be said in addition, that in the cases of chronic constipation dependent upon congenital malformations a correct diag- nosis as to the exact condition present will be almost impossible (diaphragm in the rectum excepted). CHAPTER IV HABITUAL CONSTIPATION The normal infant has from three to four evacuations, rarely five, in the twenty-four hours. The reason for this frequency is that the simple aliment of the infant is very rapidly elaborated into the proper condition for absorp- tion, and that in order to be quickly absorbed it passes very rapidly over the whole intestinal surface, through the canal. The discharges, which are made up of undigested fatty matter, epithelial cells, detritus from the intestinal canal, intestinal mucus, and coloring matters from the bile, are yellow in color and of pap-like consistency, thinner in breast-fed, thicker in hand-fed infants; with no peculiar odor ; occasionally they have a slightly sour smell. Under certain influences, by which the peristaltic func- tion of the intestinal canal is disturbed, the discharges are retarded, diminished in number, and reduced to one a day, one every other day, or what is of more rare occurrence, one in three or four days. The disturbance of peristaltic function may be in the nature of : (a) An impairment of physiological action, — atony of the intestine. 422 HABITUAL CONSTIPATION 423 (&) A perversion of the physiological action, — spasm of the intestine. *********** Habitual Constipation due to Atony An atony of the intestine may result from a variety of causes ; it may be due : 1. To maternal influences. 2. To drugs. 3. To faulty alimentation, to improper feeding. 4. It may be the consequence of a preceding intestinal catarrh. 1. To Maternal Influences. — Much observation has shown that the infants of constipated mothers are them- selves constipated, or have a marked inclination thereto. In my own experience I have seen infants who from the very earliest period of infantile life (after the third day, when the secretion of the mother's milk properly begins) did not have more than one stool per day, and that of a consistency much firmer than usual. In these cases an investigation as to the habit of the mother disclosed the fact that she was generally constipated. Whether this is due to an inherited sluggishness of the intestine or is dependent upon the mother's milk is still a question. Vogel ^ states that the milk of the mother was examined, and nothing at all abnormal found therein. In a few cases in my own practice where for one reason or another the mother's breast had to be given up, and artificial feeding resorted to, considerable improvement 1 Diseases of Children. 424 CONSTIPATION IN INFANTS AND CHILDREN followed. In some other cases where the mother was treated for the constipation and relieved, the infant was also much improved. These facts would seem to indicate that it is rather the milk which, partaking of the nature of the person secreting it, is binding. 2. To Drugs. — It is well known that brandy, whisky, or gin are given to infants in innumerable cases, and almost from the first hour of extra-uterine life. With many midwives, nurses, and good old ladies it is thought impossible to raise a child without the occasional use of these alcoholic stimulants. In other innumerable in- stances resort is had to stronger agents, the opiates, which are administered in the form of paregoric or soothing syrups. The purposes of such administration are sup- posedly to relieve colic, but very much more frequently to put the baby in a stupor, and keep it from crying whilst the mother or nurse are elsewhere, and, for them, more pleasantly engaged. The result is a constipation more or less obstinate, and a very dyspeptic stomach. ' 3. To faulty alimentation. To improper feeding. A. The Breast Milk. — (a) The breast milk may con- tain too great a percentage of casein and too small a quantity of fat.' In the early period of infantile life the efforts at digestion of too great a quantity of solid matter and the carrying forward of it soon exhausts the strength of the intestinal muscle, and inertia follows. (6) The milk may be deficient in the percentage of 1 Widerhofer, Gerhard's Haudbuch d. Kinderkr., Bd. i, Th. 2, article " Obstructio Alvi." HABITUAL CONSTIPATION 425 suo-ar.' It is clcaimed that lactose, or milk sugar, stinm- lates peristaltic action, i.e. that it has some mild laxative properties; a milk deficient therein would naturally be- come somewhat binding. Though one or the other of these defects in the mother's milk may occasionally account for the constipation, still in the majority of cases nothing will be found therein on the most careful analysis, and only the constipation of the mother will explain the constipation of the infant. B. Artificial Foods. — I. Cow's milk, when given insuf- ficiently diluted, does, in many cases, produce constipation, especially in the cooler months of the year. The hard, firm coagulum of the cow's milk taxes all the strength of the intestinal tract, both as to its digestion and transpor- tation, and atony from the stomach down follows. It may be also that a sort of packing of the canal by the milk coagula causes the constipation. II. The various infants' foods have all been accused of constipating, more or less, the infants fed upon them. III. At a later period, the feeding with amylaceous articles — bread, tapioca, arrowroot, potato pap, corn- starch — tends to constipate.^ Improper Feeding. — There is one factor that I hold more responsible for constipation in the cases of children fed with cow's milk (and not infrequently in the case of breast-fed children) than the casein, and that is improper feeding. It is strange, but nevertheless true, that many mothers seem to believe that a baby's stomach is made of some elastic material, that you can put any quantity of 1 Jacobi, "Constipation iu Infants," American Journal of Obstetrics, 1869. ^ Widerhofer, loc. cit. 426 CONSTIPATION IN INFANTS AND CHILDREN food into it, and that the more you put in the better it is for the baby. I have already called attention to this point in my article on " Summer Complaint," > and my experience there has been verified here. Infants are fed every half hour ; ui fact, every time the baby cries the breast or bottle is pushed into its mouth. One hour is really a very long interval. When, however, the physi- cian asks how often do you nurse the baby ? he will, as a rule, be glibly answered, " Oh, every two hours " ; only after careful cross-questioning will the truth be disclosed that instead of once every two hours, the infant is fed twice (and I have known cases where it was thrice) every hour. Then as to quantity. Others, though they observe the regulations as to time, will disregard those as to quantity. I know of instances where babies two or three months old were given six to eight ounces of food at each feeding. These sins of omission and commission, to which the general practitioner as a rule pays but little attention, do not pertain to the lowly alone, but are found amongst the most refined and educated of our people, even among medical men in their own families. This overfeeding, whether of frequency or quantity, produces an atony of the stomach (where proper attention is not paid to cleanliness a catarrhal condition is devel- oped), and as a result we have constipation, just as we have it with atony or catarrh of the stomach in the adult. Sometimes as a result of the large quantity of flatus developed in these cases of overfeeding, we have portions 1" Summer Complaint, A Clinical Contribution to the Etiology, Pathol- ogy, and Treatment of the Disease," Neio York Medical Journal, 1892. HABITUAL CONSTIPATION 427 of the intestine distended beyond measure, and other parts of it paralyzed, as it were, as already described elsewhere. Again, we may have a perversion of peristaltic action in con- sequence of a hyperirritation produced either by the masses of alimentary matter or by the gases ; namely, spasmodic contrac- tion of the intestine (generally with more or less pain, excep- tionally without it). 4. It may be the Consequence of a Severe Catarrh. — Severe catarrh of the intestinal tract is frequently fol- lowed by constipation. The exaggerated action during the catarrhal period exhausts the normal vigor of the muscular coat, and leaves it in an atonic state. The secretory apparatus in the mucous membrane becomes like- wise impaired, and, owing to this impairment and the atony of the muscular coat, the secretion of mucus, so necessary for the proper onward movement of the mate- rial in the canal, is deficient in quantity, and perhaps also in quality. CHAPTER V HABITUAL CONSTIPATIOi\ DUE TO ATONY ^Continued) Other Causes Besides the palpable and clearly recognizable causes which have been set forth, there are others which are counted as among the factors of habitual constipation; some, whose relationship is very questionable, others, not recognizable. I. Insufficiency of food. This, as has been already explained elsewhere, cannot be regarded as a cause of constipation. The infrequency of fsecal discharges, the result of insufficient food, is not constipation. II. The too great length of colon cannot, with all due deference to the eminent gentleman who suggested it,^ be considered a cause of habitual constipation. There is not the least evidence therefor. In the one case re- ported in support, the constipation depended upon the misplacement, and not upon the too great length of the colon. On the other hand, it may be asserted that there is really no such a thing as too great a length ; the colon is of proper length for the period of life, and required to be so for the proper absorption of the necessary quantity of nutritive material ; if it were shorter, the food would ^ A. Jacobi, American Journal of Obstetrics, 1869. 428 HABITUAL CONSTIPATION DUE TO ATONY 429 pass out too quickly and the infant would be starved. This is clearly shown by the fact that as the absorbent power of the individual portions of the intestinal canal become better developed, greater, the length of the colon diminishes. III. Too scant a secretion of intestinal mucus. This may depend upon insufficient development of the secret- ing apparatus of the intestinal mucous membrane. It may be due to the atonic condition of the whole intestine, or it may be the consequence of a catarrh, as already explained. IV. Congenital hypoplasia of the muscular coat may be a cause of constipation. See Part I. V. Constipation in consequence of dilatation and hyper- trophy of the colon. Hirschsprung reports the following cases : Case 65. A child born in the maternity hospital at Copen- hagen presented the peculiarity that, despite different laxatives administered, it had no stool. The same sluggishness of the intestines continued in the following months, and the most diverse remedies were employed. When a discharge was obtained, it was always of normal consistence and appearance. The child was otherwise well, and continued to develop nicely upon breast milk and Zwieback pap. For relief from this trouble it was brought to the policlinic. When I saw it here for the first time, the child had had but one small stool, a few hard scibala, in the past fourteen days. Nevertheless, the child did not appear to suffer any, and its appetite was always good. In the rectum an accumulation of scibala was felt which was removed by means of the finger and rectal injections. By the aid of different purgatives, the bowels were kept fairly open, and the condition continued good for a while ; when the appe- tite began to fail, the cheerfulness to disappear, and the skin took on a sickly look, the child was, at the request of the mother, received into the hospital. Age, eight months ; weight, 9000 430 CONSTIPATION IN INFANTS AND CHILDREN grammes ; state of nutrition, satisfactory. During his whole stay in the hospital, our attention was entirely directed to the abdomen, especially to its evacuation. As a rule, the boy had no fever ; vomited only exceptionally ; appetite very good ; in short he did not make the impression of being very sick. Never an evacuation spontaneously, and all our efforts were directed to effecting this. When a motion was obtained, the belly diminished in size, and the child evidently felt much relieved. The improvement was always of short duration. At the time I had not seen a similar case, and none was known to me from the literature. It appeared to me that a constric- tion of any part of the intestinal tract was out of question. The fact that a thick elastic tube more than an ell long could be introduced with greatest ease, and that on occasional explo- ration of the rectum it was generally found filled with faecal masses, spoke very clearly against any stenosis and for an atony of the intestinal tract. The treatment applied to rem- edy this condition proved futile, but by the daily administra- tion of a purgative combined with rectal injections the bowels were fairly well regulated. The abdomen was rarely distended to any extent, and the child left the hospital ; he had lost 700 grammes in weight during his stay therein. He remained at home but a short time. The first eight days the child Avas very well and even had spontaneous discharges which were rather thin. Then the belly again became very much dis- tended, the discharges were frequent and thin, and he died on the same day that he was again brought to the hospital. His weight was 6900 grammes. Fost-mortem Uxamination. — On opening the abdomen, sev- eral enormously distended loops of intestine present them- selves ; they are the sigmoid flexure, and the still more markedly dilated transverse colon. The other parts of the colon, with the exception of the rectum, are also dilated. No constriction anywhere. These parts are not alone dilated, but their walls throughout their whole extent are also very much thickened, especially the muscular layer. The mucous membrane of the more or less dilated parts is sown with ero- HABITUAL CONSTIPATION DUE TO ATONY 431 sions and ulcerations which present marked differences as to size and depth. There are small superficial erosions and ulcerations barely the size of a pin's head which penetrate the whole depth of the mucous membrane. There are small superficial ones, and larger, formed apparently by the conjunc- tion of two or more ulcers, little bridges of mucous membrane traversing the ulcer being noted. At certain points the super- ficial surface of the intestine presents a peculiarly figured appearance. All the ulcerations and erosions are of round or oval form with smooth edges as if cut out with a punch. Here and there the borders are somewhat undermined. No- where intumescence of the follicles. On the serous surface not a trace of disease. Ligamenta and haustra coli not recogniz- able ; the appendices epiploicse strongly developed. The mes- entery of the sigmoid flexure is high, broad, and markedly thickened with rows of hypertrophied (to the size of a bean) bluish mesenteric glands. At the lower part of the ileum the plaques of Peyer stand out prominently. Otherwise, nothing abnormal in the body. Case 66. Waldemer H., nurseling, seven months old, re- ceived into the hospital April 19, 1888. Suffered with consti- pation from birth, and only by the daily administration of purgatives could the bowels be kept open. Defecation was painless ; in fact, the child but rarely complained ; no eructa- tion, no vomiting; developing very well. Occasionally the abdomen became very much distended, and lately it has gained in circumference. Since a month the distention has become so marked that the distressed mother brought the child to the hospital for relief. Punctures were made with a very fine trocar, and flatus evacuated; the abdomen became somewhat smaller. By means of daily doses of castor oil and of rectal injections regularly administered, the bowels were kept open, and the boy left the hospital in a rather satisfactory condition. In a very short time, however, the abdomen again became dis- tended, despite the now numerous fsecal discharges. He vom- ited but once; he seemed to suffer considerable, cried much, and was therefore brought to the children's hospital. He was 432 CONSTIPATION IN INFANTS AND CHILDREN an emaciated, delicate child, with an enormous belly, fifty centimetres in circumference. The loops of the intestine were clearly outlined on the abdominal parietes. Temperature in rectum 38.4°C. (= 100.5° F.). No excrement in the rectum, but a thin discharge follows the withdrawal of the finger. During his stay at the hospital, which was between four and five weeks, the diarrhoea, the distention of the abdomen which ranged from forty-one to fifty-six centimetres, and disappeared altogether toward the close of life, and the marked emaciation were the most prominent symptoms. The microscopic exami- nation of the rectal dejections showed finely granulated detri- tus, many large and small fat globules, granulated epithelium, and pus cells in great numbers. Post-mortem Examination: The colon very much dilated (somewhat less than in the previous case, sixteen to nineteen centimetres), but the hypertrophy was more pronounced. On the mucous membrane there are seen the same erosions and ulcerations, round and oval as if punched out Avith a punch, penetrating the whole depth of the intestinal wall. Besides these, there are found in this case single, large, and deep ulcerations, which penetrate as far down as to the serous cover- ing, and cause it to bulge out like a pocket without the least appearance on the spot of peritoneal inflammation. The cavity is empty, but has, undoubtedly, at one time held fluid con- tents. We find, indeed, spots where the process has remained at a preceding stage, whereby a better understanding of it is obtained. Not far from the ulcers just mentioned we find an abscess beneath the mucous membrane measuring two centi- metres in one and one centimetre in another direction. The incision shows us a whole meshwork of cavities in the sub- mucosa with purulent contents. Like cavities are found at other points ; not very many, however. That these abscesses may, in their progress, ulcerate through the mucous membrane, and also penetrate through the intestinal wall to the serous covering, is very apparent. Hirschsprung regards the ulcerations as secondary to the dilatation and hypertrophy.^ As regards the development of 1 See Part I., " Consequences of Constipation." HABITUAL CONSTIPATION DUE TO ATONY 433 the latter, he does not care to express an opinion ; only this he would say that, considering the fact that the constipation began almost with the first moment of life, it appears indisputable that the etiological factor must have been of intra-uterine ori- gin, either an anomaly of development or some morbid foetal process. 1 1 Jahrb. f. Kinderheilkunde, 1887. I CHAPTER VI HABITUAL CONSTIPATION DUE TO ATONY (Continued) Habitual Constipation in Older Children Atony of the intestine in older children is due to the same causes, in so far as they pertain to this period of life, that give rise to it in the adult. A diet of too con- centrated food, a sameness in the dietary, too coarse food long continued, too little exercise, etc., all tend to retard the fsecal evacuations. Two factors, however, merit spe- cial mention here, namely : I. Too Little Time taken for Defecation. — It will be found, and I have found it so rather frequently, that very lively, active, playful children become constipated for the reason that they do not take sufficient time to properly fulfil their duty to cloacinse. They will rush to the closet, and barely has the first portion of faecal matter been discharged when their mind is upon something else, they are up and away to play. Some may not even wait for this much ; they sit upon the closet for a mmute or two with a mind upon a dozen other things, and the discharge not immediately following, they leave to attend to matters more interestmg to them. Marked atony of the mtestine follows, and constipation results. Parental inattention plays an important role in the constipation of children, especially of the category under 434 HABITUAL CONSTIPATION DUE TO ATONY 435 consideration. Many mothers, perhaps most mothers, do not think it at all necessary to see to it that their children have regular motions. The fact that the child goes to the closet, or says that it does, suffices for them. When the physician makes inquiry upon this point, he will be told, " Oh, yes ! my child is regular, she goes to the closet every day." Of what value such testimony is, is very well illustrated by Case 4 of my article on "Intestinal Obstruction,"^ where the mother complained that her daughter was troubled with diarrhoea, whilst in fact the bowels were obstructed. When I receive the above an- swer, I always ask again, " How do you know that the bowels have moved ? Have you gone to the closet to look, or have you inspected the vessel ? " Then they seem amazed; "No!" I think too much stress cannot be laid upon this point, and when I am called upon to treat constipated children, I always strenuously insist upon it that the mother or some other trustworthy person shall make it her business to inspect the bowl or vessel after the child has used it, so that she may know by ocular demonstration whether the child has really had an evacu- ation, whether the faeces are normal in character and suf- ficient in quantity. II. Overstudy. — The crowding of the young mind with study exhausts the brain and nerves, weakens the muscles, and a general apathy follows. Moreover, chil- dren so crowded with mental tasks have no time for physical exercise ; their studies keep them in the house, and thus deprive them of that abundance of oxygen so necessary to their well-being. The appetite is poor, and 1 American Journal of the Medical Sciences, 1886. 436 CONSTIPATION IN INFANTS AND CHILDREN frequently capricious, and they eat very sparingly and very . daintily ; the taste for the coarser aliments, so neces- sary to the proper functioning of the bowels, is lost. As a result of all this, constipation, very often of a most obstinate character, ensues. CHAPTER VII SYMPTOMS AND DIAGNOSIS Symptoms. — With children, as with adults, the symp- tomatology of constipation has a very wide range. Whilst with some not the least distm^bance of the general econ- omy is manifested, with others symptoms indicative of serious trouble may present. The symptoms, as already given in the preceding sec- tion, are diminution or loss of appetite ; coated tongue ; more or less foul breath; discharge of offensive flatus; headache. The child loses its cheerfulness, and becomes nervous ; it sleeps badly, restlessly ; wakes up several times in the night. Night terrors and grinding of teeth may be due to constipation. Colic, very severe colic, is very frequently one of the manifestations of a constipated state. Occasionally, but not very frequently, we have convulsions as one of the symptoms. They are most likely to occur, however, when some hard substance has been swallowed, and presses upon the rectal nerves or irritates the intestinal nerve filaments. Fever. — An elevation of temperature is sometimes the result of a constipation. Usually it is indicative of a sharp putrefactive process going on somewhere in the bowel. Faeces. — The faeces are changed in character and 437 438 CONSTIPATION IN INFANTS AND CHILDREN appearance. The great loss of water is one of the most characteristic features. The fteces are of firm consist- ency, sometimes very hard, dry, and scybalous in form. Occasionally they may be clay-like and sticky. They vary in color from a dark green to a deep yellow, to an ashy gray in milk-fed infants; in children fed upon a mixed diet the color is the same as that of adults, — a lighter or darker brown according as more or less biliary matter is contained therein. When the stool is clay-like in character, it has usually a dark, tarry color. There is sometimes found adherent to the hard scybala, bloody mucus or pure blood derived from a superficial erosion of the mucous membrane. The scybala becoming firmly adherent to the mucous mem- brane, the separation therefrom, by the powerful peristalsis excited by one means or another, leaves a superficial erosion of said mucous membrane. Defecation. — The act of defecation is occasionally more or less painful, and generally requires much effort. The face of the child during the act becomes red, turgid, even reddish-blue; it is covered with perspiration. Great down- ward pressure is made, and finally one or two small, hard lumps are discharged, or, perhaps, nothing more than a little flatus. Diagnosis. — The diagnosis of retardation of f ascal dis- charges is one the most readily made. It is apparent. What is more difficult is to differentiate the habitual con- stipation due to an atonic state of the intestinal tract from constipation, the result of insufficient food, and from chronic constipation dependent upon morbid processes in the abdomen or elsewhere. As regards the first a care- SYMPTOMS AND DIAGNOSIS 439 fill inquiry into the history and life of the infant or child, the quantity and character of the food taken by it, — and as to the latter a careful examination upon the lines laid down in Part I., will soon disclose the truth to us. In all constipated infants and children who are fretful, given to crying much, the anus should always be examined for a possible fissure or excoriation thereabout. CHAPTER VIII TREATMENT OF CONSTIPATION DUE TO ATONY OF TPIE INTESTINE (Infants) I. When the constipation of the infant is dependent upon the constipated habit of the mother, we will en- deavor to remedy this. In the earliest part of the post-partum period, by the regular administration to the mother of some mild but efficient cathartic, — magnesia, Rochelle salts, the tonic laxative,^ or some one of the laxative mineral waters, as Hunyadi Janos, Rakoczy, Villacabras, or Hathorne (Sara- toga), all in appropriate doses, just sufficient to keep the bowels soluble. The good effects of this treatment will soon manifest themselves in the greater solubility of the infant's bowels. It is, of course, absolutely necessary to avoid such remedies as have a subsequent constipating effect, as castor oil or rhubarb, and such as have a tendency to gripe, as otherwise, in the case of the latter, the child Avill be severely troubled with colic. At a later period, when the mother has recovered her former vigor and is able to be up and about, we will treat her constipation upon the principles and by the methods laid down in Part I. 1 See " Formulary," Part 1. 440 CONSTIPATION DUE TO ATONY OF THE INTESTINE 441 Generally, with the relief of the mother the constipa- tion of the infant will be cured. II. Where the constipation is dependent upon a faulty composition of the mother's milk. (a) Too great a Percentage of Casein. — Whether we are to understand by this an amount beyond what has been found to be the maximum/ is not explained. In the sense of an abnormally high percentage of the nitrog- enous element, I have not myself seen a case or read one reported. When we are confronted by such a condition, or where the percentage of casein, though within normal limits, is nevertheless too large for the digestive capacity of the child, we must attempt to correct this by dietary meas- ures. Theoretically, we should be able to accomplish something, and experimental observation seems to verify this to some extent,^ by putting the mother upon a diet composed mainly of carbohydrates and fats, with but a minimum of the nitrogenous element, and that only in the form of lean meat. In addition, we may avail ourselves of the benefits to be derived from a course of mineral waters. The alkaline waters, as Vichy or Bilin, or the milder muriatic waters (alkaline-muriatic), as Selters, Ems, Luhatschowitz, or a bitter water, as Kissingen or Friedrichshall in minimal quantity freely diluted, may be prescribed.^ Where with all these we do not succeed, and the diges- tive disturbances are prolonged and tend to become seri- 1 The casein in mother's milk ranges from 0.18 to 1.90. Foster, Physiology. See references there. ' Balneo-Therapie, Handbuch der Allgemeine Therapie (Ziemssen) ; " Mineral Waters," Dictionary of Medicine, Quain. 442 CONSTIPATION IN INFANTS AND CHILDREN ous, the question of a wet nurse or a resort to artificial feeding must be considered. (&) Too Small Ferceiitage of Sugar. — Beve, also, we should, at the very first, endeavor to remedy the defect by proper dietary regulations. Such articles of food as are rich in starch— potatoes, rice, tapioca, arrowroot, white bread— should constitute a large part of the diet, with the nitrogenous element and the fat in just proportion. In addition, dishes prepared with an abundance of sugar and sugar itself should be taken freely.^ Jacobi seeks to remedy the difficulty by administering a quantity of sugar to the infant to make up the defi- ciency. He directs that the child be given from thirty to sixty grains (2.0-4.0) of loaf-sugar dissolved in tepid water before each nursing.^ If, as claimed, lactose or milk sugar possesses laxative properties, it is the better form of sugar to administer. Maltose or malt sugar can also be employed for the purpose. This latter method is very well as a temporary makeshift until the mother's milk can be brought up to the normal stand- ard, and for the exceptional cases where this cannot be accom- plished. III. In infants fed with cow's milk the constipation is due to the greater amount of casein that this contains and its more difficult digestion. To remedy this, the milk must be properly diluted so as to reduce the percentage of casein, and make it conform to that found in breast milk. Ordinarily it may be said that in the early period of infantile life the dilution should be one part milk and 1 Foster, Physiology, " Sugar." American Journal of Obstetrics, 1869, loc. cit. CONSTIPATION DUE TO ATONY OF THE INTESTINE 443 three to four parts water ; after the thu'd month, one part milk and two to three parts water ; after the fifth month, one part milk and one to two parts water ; ^ after the eighth month, the milk can be given undiluted. Under the circumstances here considered, oatmeal water, which is perhaps possessed of some laxative properties, will be an excellent diluent. Moreover, it prevents the too firm and too close clotting natural to the casein of cow's milk. As the dilution will also reduce the fat and sugar con- stituents below the normal limit as fixed by breast milk, we will have to make good this loss by the addition of cream and sugar (loaf or milk sugar). For further details on this subject see the Cyclopaedia of Diseases of Children, American Text-book of Diseases of Children, Diseases of Children, by J. Lewis Smith, and that very excellent little book by Dr. Louis Starr, the Hygiene of the Nursery. Pap-fed children must be brought back to a milk diet. Condensed milk prepared with oatmeal water will be the most suitable food at the outset. IV. Improper Feeding. — As already stated, so far as my own experience goes I am decidedly of the opinion that the greater part of the difficulties encountered in feeding with cow's milk (and not infrequently the diges- tive troubles of breast-fed infants) are due to improper feeding; namely, they are fed too often or too much, or both. ^ The more or less of the water depends upon the digestive capacity of the child. See the tables of dilution of Monti, Uffelmann, and of the Verein der Medicinal Bearaten, etc., in Wie behutet mann Leben u. Gesundheit der Kinder, by Ernest Briicke, Vienna, 1892. 444 CONSTIPATION IN INFANTS AND CHILDREN This point, upon which too much stress cannot be laid, must be regulated in accordance with the well-formulated rules that have been established, and that a large and long experience has demonstrated to be correct. Breast-feeding. One breast only is given at a nursing. For the first week after the establishment of the flow, the child can be given the breast every hour and a half from 5 A.M. to 11 p.m. When the flow is abundant, the breast having a very abundant supply, every tivo hours will suffice. At this early period one nursing in the course of the night (about 2 a.m.) may be allowed. After the first week to the end of the tenth week, every two hours from 5 a.m. to 11 p.m. No feeding during the night after the first week. From the eleventh week to the end of the fourth month, every two and a half hours from 5 a.m. to 1 1 p.m. From the fourth month to the end of the tenth month, every three hours from 5 a.m. to 11 p.m. The intervals of time between the feedings, as above given, are adapted for the great majority of infants ; here and there a child with strong digestive capacity may re- quire either a shorter interval or a larger quantity at each feeding. The former is the preferable to do. Where mixed feeding is resorted to, i.e. breast and bottle (and it is always desirable to retain the breast in function as much and as long as possible, especially in the early period of the infant's life, for the benefit of both mother and child), the breast and bottle must never be given together at one nursing ; they should be CONSTIPATION DUE TO ATONY OF THE INTESTINE 445 BOTTLE FEEDING Age Intbrval Quantity at Each Feeding During the first week, and early part of secoiiQ. Every two hours from 5 A.M. to 11 P.M. Occasionally once or twice during the night. One (1) ounce. From the middle of the second to the sixth Every two hours from 5 A.M. to 11 P.M. No One and a half {\\) ounces. From the sixth week to + n P pn n r\T cppmi c\ month. Every two hours from ^ A TW 1 1 13 HT Two (2) ounces. At thp third mnnth XjVcIj tWU clilU. cXi XictU. hours. (^Same hours.) -I wo dna. a naii \^^) ounces in the first part, three (3) ounces in the latter part of the month. At the fourth month. Every two and a half hours. (Savie hours.) Four (4) ounces. At the filth month. Every three hours. {Same hours.) Five (5) ounces. At the sixth month. Every three hours from 7 A.M. to 10 P.M. Six (6) ounces. At the seventh month. Every three hours. Seven (7) ounces. At the eighth month. Every three and a half hours. Eight (8) ounces. 446 CONSTIPATION IN INFANTS AND CHILDREN used separately; at one nursing' the breast, at another, the bottle. The physician can make himself certain that the regi- men he has prescribed gives a sufficient supply of food by occasional and careful weighing of the infant, and noting thus whether it is gaining in due proportion or not. Children that are thus properly fed are, as a rule (breast-fed infants always), free from that irritability which causes the long and harassing crying spells which are always more or less present in overfed children, and which with them are always an expression of a dyspeptic condition, and not infrequently of a beginning catarrh of the stomach. They will also be free from the frequent attacks of colic to which overfed children are so liable. With older infants, one and one-half to three years, the dietary errors that demand our attention vary with the station in life of the parents. Among the middle and poorer classes, the children, already at an early age, are fed with gross coarse food such as is furnished for the adults ; and dyspepsias, even ectasias of the stomach, and constipations are frequent results. Among the wealthy class the other extreme is the rule, — too bland a diet is provided. These faults of alimentation must be corrected, and a proper dietary for the children prescribed. For additional information upon the feeding of infants, see Diseases of Children, by J. Lewis Smith, the Ameri- can Text-book of Diseases of Children, and the Hygiene of the Nursery. I do not think it necessary, ordinarily, to prescribe the free administration of water to very young infants except in the hot months when the system is continually drained CONSTIPATION DUE TO ATONY OF THE INTESTINE 447 thereof by the very abundant perspiration. There is suffi- cient water in their food. The dryness of the faeces is not due to an insufficiency in the quantity of fluid, but rather to the long retardation of the matters in the bowel and their consequent inspissation. V. From Drugs. — It will certainly be admitted that to administer drugs or alcoholic liquors to an infant to stupefy it, so that mother or nurse may enjoy undisturbed their selfish pleasures, is criminal. No physician who has the welfare of his little patient at heart should hesi- tate one moment to denounce such an abominable prac- tice. What seeds for future evil are thus laid ! But even for those frequent infantile colics (due to flatu- lence, from indigestion, or to the swallowing of much air in the act of nursing) there is no necessity for a resort to opiates or brandies or whiskies. We have other agents equally, and, indeed, much more effective and withal harmless. These are : 1. First and foremost milk of assafoetida. Made as already described here, there is nothing that will so quickly relieve the colicky pains of the infant. Infants take it readily, especially if sweetened by the addition of a little sugar to each dose as administered. One-half to one teaspoonful can be given at a time, and repeated every fifteen minutes until relief is afforded. Usually not more than one or two doses will be required to accomplish this purpose. With a bottle of this preparation at hand, infantile colic loses its terrors, and heartless mothers and worthless nurses are deprived of all grounds for their nefarious drugging. 2. Star anise (Illicium anisatum, Fructus illicii) is also very good, though inferior to assafoetida. It can be used in the form of a tea ; three to five pieces of star anise are broken up, and one-third of a cupful of hot water poured over them and al- lowed to steep for about ten minutes. When cooled down to the right degree of warmth, sufficient sugar is added to make 448 CONSTIPATION IN INFANTS AND CHILDREN the tea palatable, and three to five, or more, teaspoonfuls thereof are given at a time. Essence of anise {Essentia anisi): ten to twenty drops in one-third of a teacupful of warm water sufficiently sweetened, and administered as directed above. 3. Caraway {Oarum, Kummel) is also serviceable. A small quantity of the seeds (one-third of a teaspoonful) is bruised upon powdered sugar and rubbed up with it ; four or five table- spoonfuls of hot water are poured over it ; a tea is thus made, and administered as directed above. Special Measures Besides these more general measures, we will make use of others more especially addressed to the bowels and to their evacuation. I. Medicines. A. For the New-horn. — For the very earliest period of infantile life, the first month, we can avail ourselves of the laxative action of Manna. — It may be prepared after various formulae or simply as a tea, — a solution. A good-sized lump of manna (or two or three smaller lumps) is dissolved in four or five tablespoonfuls of water, and then administered freely to the infant. As the age progresses, from two weeks on, larger doses are required. It is generally effective. Syrup of Rhubarb. — One-third to one-half teaspoonful every two or three hours. This has the disadvantage, how- ever, of a rather constipating after effect. Syrup of Rhubarb and Manna. B. For Older Infants. Magnesia (Carbonate or Calcined, usta) grs. v-3 ss. It can be given in sweetened water (sweetened oatmeal water). CONSTIPATION DUE TO ATONY OF THE INTESTINE 449 Rhubarb, syrup, wine or powder. The latter form usu- ally in combination with magnesia.^ J. Lewis Smith 2 prescribes the following formula for con- tinued use upon the supposition that an insufficiency of fat and sugar is the cause of the constipation. 5 Ole. Morrhuse S iv Aq. Calcis Syrup. Calcis Lactophosphat. aa S ii M. ft. Mixt. Sig. Shake bottle. One-half to three-fourths teaspoonful, three times daily. This is an excellent prescription for the constipation of rhachitic children. II. The clyster can be used from the earliest period of infantile life. Even with the new-born when there is retention of meconium a warm rectal injection may be given to provoke its discharge. Instruments. — A glass syringe should never be used. It is a dangerous instrument ; a little unskilfulness on the part of the mother or nurse, and a laceration or ero- sion of the delicate mucous membrane is produced. A sudden movement on the part of the child, and the instru- ment may be broken, and injury result. With all these disadvantages there is but little force to it, insufficient even for the infant. For the very young infant the hard rubber syringe of three ounces' capacity, with a fairly long and smooth nozzle, is the best instrument. It can be used for the injections of water or the clysma of oil already described. For older infants, from the third month on, I prefer to use the fountain syringe. 1 See " Formulary," Part II. 2 Diseases of Children. 450 CONSTIPATION IN INFANTS AND CHILDREN How to administer the Enema. — When the small, hard rubber syringe is used, a sufficient quantity of water hav- ing been drawn in, the tip is well anointed with vaseline (or oil), and the child, lying in its crib or placed upon a couch or on the table, is laid on its left side or on the back with the legs held well drawn up; the buttocks are separated, and the point of the syringe, directed some- what to the left, gently and gradually insinuated past the sphincter into the rectum. The piston-rod (one with a ring at its further extremity is best) is then pushed for- ward, not too fast, and the fluid thrown in. It may also be given with the child in this position : AVhen the fountain syringe is used, the mother may seat herself in a low chair with the infant placed upon her knees, belly downward, the thighs of the infant just coming over the mother's knee and hanging down. The reservoir of the syringe (the fountain) is placed at a height of about one foot (to a foot and a half) above the infant's buttocks. The rectal point, well anointed with vaseline (or oil), is introduced into the rectum, and the water allowed to flow. Given in this way, the injection is always effective, and never has harm resulted therefrom. Where the mother is alone, without a nurse or assist- ant, this last position is the better for the easy and rapid accomplishment of the purpose. Quantity. — The amount of fluid to be used for an injection varies with the age of the infant ; for the new- born, three-fourths to one ounce (one and one-half to two tablespoonfuls) ; from one month to six weeks, one and one-half to three ounces (three to four tablespoonfuls); at three months, two and one-half ounces (five tablespoon- CONSTIPATION DUE TO ATONY OF THE INTESTINE 451 fills) ; for a child of one year, five to seven ounces (some- what according to the size of the child). Fluids. — Water is, of course, the fluid most commonly- used. Some medicate this, to make it more stimulating, with salt, soap, castor oil, or glycerine. I prefer to use plain water, and have always found that, injected with the fountain syringe, equally as good an effect was obtained with the unmedicated as with the medicated water, with the further advantage of the minus of the local irritation which the various agents employed tend to excite. The only addition to the water that I occasionally advise is that of lac assaf cetidse, 3 ii- S ss (two teaspoonf uls to one tablespoonful), in cases where there is much flatulence. The water should be a little more than lukewarm, — 93° F. to 95° F. This also contributes to its effectiveness. When (in older infants) the injections are to be used for any length of time, the temperature may be gradually reduced (two or three degrees at a time) until water at a temperature of 78° F. to 75° F. can be injected without discomfort. Oil. — The technique and details of the oil clyster have already been given. Here it need only be said that the oil injection is equally applicable to the young infant, especially where there is a tendency to marked inspissa- tion and hardening of the faeces. One to four teaspoon- fuls, according to the age, of warmed olive oil-^ can be injected into the rectuni, and if necessary followed in four or six hours by an injection of water. Glycerine. — The glycerine injection, i.e. the injection of a quantity of glycerine into the rectum, whether pure 1 See page 354. 452 CONSTIPATION IN INFANTS AND CHILDREN or diluted somewhat with water, should not, I think, be used in infants. It is far too irritating to the parts, causes considerable straining, and a prolapse of the rectum, — a not uncommon occurrence in young children, — or even a proctitis may result therefrom. III. Massage. — As with adults so with infants, mas- sage is the most potent remedy for this form of constipa- tion. No matter what the cause that may have primarily produced it, massage will, in almost every instance, prove effective in overcoming the atony, and this frequently in a very short time. This is the consensus of experienced paediatrists,^ which my own personal observation confirms. The following case very well illustrates its effectiveness and the rapidity of the action : Case 67. Baby G., cet fourteen months ; breast and bottle fed; stout, healthy-looking boy. In the summer of 1893 he suffered severely with intestinal catarrh, which lasted a long time and reduced him very much. His grandmother brought him to me for relief from constipation, which is said to have supervened shortly after the cessation of the diarrliceal affec- tion, and with which he has been troubled for over five months now, and which is daily growing worse. It requires now larger doses and stronger to give him a free evacuation. The symp- toms are very characteristic ; when at stool he strains until he is almost purple in the face ; he cries out, and sometimes utters piercing shrieks. The evacuation, unless the result of a pur- gative, consists of a few scybala of stony hardness, usually cov- ered with mucus, which very frequently is streaked or tinged with blood. When done, he sinks back exhausted, and it is an hour or more before he has recovered himself. The time of stool for the infant is an hour of dread for the parents and grandparents. A physical examination revealed nothing especial. 1 A. Jacobi, J. Lewis Smith, Troitzky, Baginsky, Henoch, Kaniitzky. CONSTIPATION DUE TO ATONY OF THE INTESTINE 453 Diagnosis. — Constipation consequent upon intestinal catarrh. Treatment. — The chiki is to have oatmeal porridge with milk in the morning, and twice a day a tablespoonful of mo- lasses with crumb of bread. The bowels are to be washed out every third day with a large injection, — a teacvipf ul and a half of water at a temperature of 90° F. at the outset, with a gradual reduction of the same in the course of a few weeks to 80° F. Being a very intelligent woman, I instructed the grandmother in the technique of the massage, and directed her to apply the • same every day for the first two weeks, and then every other day. In three weeks there was a marked improvement ; at the end of the second month the child was reported well. I have seen him since ; there has been no relapse ; his bowels continue to act with regularity and ease. It is of inestimable value in those dyspeptic conditions dependent rather upon insufficient development or ineffi- cient action of the digestive organs than upon an indi- gestibility per se of the aliment. Here it will not alone strengthen the intestinal muscles and invigorate the peri- stalsis, thus quickening the onward movement of the in- testinal contents, but it will also, by stimulating the circulation both in the blood-vessels and the lymphatics, forward the development of, or render more energetic, the special digestive apparatus of the intestinal tract, and fortify both the pancreas and the liver in the performance of their physiological function. It is the most important measure in the treatment of atony due to a dilatation of the bowel or a section thereof, and combined with constitutional remedies it is of the greatest service in the treatment of constipation depen- dent upon a rachitic dyscrasia. IV. A measure of secondary importance, but oi some 454 CONSTIPATION IN INFANTS AND CHILDREN utility in very obstinate cases, is the application of cold to the abdomen. The effects of cold water upon the abdomi- nal muscles and the organs beneath them have been already set forth. In young infants (three months) the only method of application that I deem advisable is this : I direct that in the course of the morning when the child is having its regular bath or wash that its belly be rubbed with a cloth dipped in cold water, temperature 80° F. to 75° and that this be quickly followed by frictions with a well-warmed towel. For older infants (ten months) we may use water at a much lower temperature, 75° F. to 65° F., or if it be the summer months, we may advise the cold bath, accustoming the child gradually thereto after the manner described. In very obstinate cases we may resort to the cold douche to the abdomen. In infants and young children it should never be given through the showering apparatus con- nected with the water pipes, but by means of a sprinkling can or the fountain syringe, a nozzle as described on page 279 being fitted thereto. V. Regularity of Habit. — It is so general a custom that it need hardly be mentioned. Even very young children, from six to seven months, and exceptionally strong ones already after the fourth month, can be accustomed to use the vessel (placed beneath an appropriate chair on which pillows are arranged, so that the child is well supported and perfectly comfortable thereon). By placing them on the vessel at a certain fixed time or times ^ of the day, a regularity of habit is acquired by the child which is cer- tainly of advantage in the treatment of the constipation. 1 After the fourth month up to the second year many children have two stools per day ; many others have but one. CHAPTER IX TREATMENT OF CONSTIPATION DUE TO ATONY OF THE INTESTINE (Continued) Older Children The treatment of constipation in older children does not differ in any respect from what has hitherto been said. The causes that lead to the retardation of the faecal discharges are very much the same as we find in adults, and their correction must necessarily be after the same methods. As regards the two factors that have been specially mentioned here : 1. When the child, too playful, does not take sufficient time at stool, the mother or nurse must accompany it to the closet, and see to it that it remain on the receptacle a sufficient length of time. Furthermore, they must not divert the child's attention by gossip on extraneous mat- ters, but rather fix its mind upon the duty before it by reverting to it in conversation, and impressing upon the child the necessity for a full and free evacuation. By such measures, even though at the outset no larger dis- charges may follow, the habit of taking sufficient time for this important physiological function will be formed, and its good effects will manifest themselves at an early day. 465 456 CONSTIPATION IN INFANTS AND CHILDREN II. When the child is overburdened with studies, it must be released from them. The regulation of this will de- pend greatly upon the age, the physical development, and the intellectual capacity of the child. For bright, intel- lectual children it will be frequently found that studies that are a mere matter of memorizing, as geography, spelling, are the hardest tasks, whilst with duller children, it is those that excite and stimulate the thinking power. With some children, bright otherwise, arithmetic and mathematics will be very hard and exhausting studies, whilst with others it will be just the reverse. Sometimes it may be necessary to keep the child out of school alto- gether. However it may be for exceptional cases, gener- ally it will su£B.ce if we insist upon these two points : 1. That the child shall have ample time to be out and exercise in the open air. 2. That it shall not study after the evening meal. The special measures to be employed are the same as have been described. Younger children up to the seventh or ninth year (ac- cording to the physical development) will be treated more after the fashion of infants. We will treat them with injections and with massage, and this latter will be that described in the second part, plus a little more force added in our manipulations than would be necessary for infants. For older children the treatment will be the same as for adults. The massage will be as described in Part I., minus a little of the force put into the execution of the manipulations in grown persons. As regards the measures of hydrotherapy, the injections or clysters have already been mentioned as applicable at CONSTIPATION DUE TO ATONY OF THE INTESTINE 457 all ages, from the very earliest period of childhood (another form of clyster (oil) has also been described). In the summer, the hot months, the cold bath is applicable even in infants ; ^ in the cold months children do not bear the cold bath well ; very young c]iildren not at all ; and with older ones much depends upon their physique and their nutrition, and not a little upon the heating facilities of the dwelling. The cold douche to the belly may be used even with young children,^ and even in the cold months. The long-continued wet applications, as the cold, wet compress,^ are not well borne by young children, and should not be prescribed for them ; for older children, from six years on, they are decidedly advantageous.* Electricity. — Children, and more particularly young children, are not very tolerant of its application. In fact, we are so generally successful with the other measures named that it will rarely be required. When its employ- ment becomes necessary, however, the modes of applica- tion are the same as for adults, as have been described in Part I. ^ See " Summer Complaint," etc., New York Medical Journal, 1892, by H. Illoway, M.D. ^ As described for infants. ^ See section on Hydrotherapy. * J. Lewis Smith, Diseases of Children. If CHAPTER X ANATOMICAL We find very frequently reference made to the ana- tomical differences between the abdominal organs of the infant and those of the adult, and from the character of some of these statements one might be led to infer that these differences existed throughout the whole period of infantile life. For a clearer understanding of this impor- tant point, it has been gone into in some detail here, more especially as it is of some importance for the practice of infantile massage. Stomach. — In 1837 Schultze wrote: "The stomach in its earliest developmental stages runs through the cylindrical form of stomach of fishes and amphibia ; for we see the stomach, in the early embryonic period, as a slight distention of the oesophagus, of cylindrical form, hanging straight down in the abdominal cavity, so that the cardia is directed upward and the pylorus downward. The transverse position of the stomach is of much later date, established only with the full development of the curvatures. The stomach of the child is rather of the spherical form drawn out lengthwise, and becomes narrower at both ends, — above at the cardia, below at the pylorus. 1 Schultze, " Ueber Art u. Verschiedenheit des Erbrechens," etc., Analecten ueber Kinderheilkunde, 1837, Bd. II. Quoted by Henschel, "Ueber Mageu- erweiteruug im Siiuglingsalter," Archiv fur Kinderheilkunde, 1891, Bd. XIII. 458 ANATOMICAL 459 The oesophagus is inserted into the fundus proper, and is at a great distance from the pylorus ; the small curvature is thus rather long drawn out. The greater curvature is less developed and almost parallel v^ith the lesser; in one word, the stomach is very much like that of the carnivora." According to the more exact description of Fleisch- mann,^ the stomach of the young infant occupies the left hypochondrium exclusively, and only when very much dilated does it extend into the left epigastrium. The small curvature lies on the left side of the vertebral column, and parallel with it, and only at its lowest part does it assume a horizontal direction, so that the pylorus lies about the middle line ; the greater curvature passes through the centre of a vertical line drawn from the xiphoid cartilage to the umbilicus. When the stomach is full, the fundus, extending beyond the cardia, forms the highest, and the pylorus the lowest point ; but only when its Avails are enormously distended does the pylorus extend beyond the median line to the right. A careful comparison of this with the description, and more especially with the chart of the adult stomach as given by Luschka,^ will disclose the fact that the infantile stomach differs but little in position from that of the adult, and that what little difference there is, is more a matter of size. The correctness of this is affirmed also by Symington,^ who says: "My own observations are in favor of the view ^ Fleischmann, Kliiiik der Pediatrik, 1875. Henschel, ibid. ^ Luschka, Die Bauchorgane des Meuschen. ^ Symington, Topographical Anatomy of the Child. 460 CONSTIPATION IN INFANTS AND CHILDREN that the shape and situation of the stomach in children are practically the same as in the adult. In newly born infcints the stomach is either empty or it contains only a small quantity of mucus. In them the long axis of the main part of the stomach is directed downward and for- ward ; there is a small fundus which projects upward and backward, and the pylorus lies in or very close to the mesial plane." It is therefore very evident that the general statement as to the marked differences as to position between the infantile and the adult stomach is only true for a very short period, three or four days, not longer; for Sym- ington^ refers to the stomach of an infant four days old occupying the same position as that of the child one year old. The most marked difference between the infantile and the adult stomach (so far as external configuration and position are concerned) is the great extent to which the former is covered on its anterior surface by the liver (left lobe), as shown in our illustrations, frontispieces I. and 11.^ Liver. — Tlie liver is of enormous size, and covers three- fourths of the abdominal cavity, the left lobe extending far over to the costal cartilages of the left lower ribs.^ It decreases in volume as the child grows older, and at the close of infantile life and the beginning of childhood, about the fourth year, according to Beneke," it assumes 1 Loc. cit. 2 See also McClellan, "Anatomy of Children " (in Cyclopedia of the Dis- eases of Children, Keating). * See frontispieces I. and II. * Deutsche medizinische Wochemchrift, 1880. ANATOMICAL 461 the position it is found in in the adult. The decrease is most rapid in the earlier months. It varies so much in size within the limits of health that its boundaries at the various periods of life cannot be given with any exactness ; moreover, the extent to which it may project beyond the costal arch (not infre- quently one to two centimetres) depends considerably upon the height of the diaphragm and the shape of the thorax.^ Bowels. — In the new-born, owing to the immense size of the liver, the whole mass of the small intestines, the descending colon, and the sigmoid flexure partly, lie in the left half of the abdominal cavity. The small intestines making many convolutions, the left colic flexure and the descending colon descend from the spleen to the upper border of the pelvis. The remaining abdominal space on the right side is occupied by the caecum and its appendix and what there is of the ascending colon. The sigmoid flexure and the rectum are rather feebly developed in the new-born, and until the second or third month have no fixed position, though they are most fre- quently found to the right. Boucart, in one hundred and fifty autopsies, found the sigmoid flexure eleven times to the left, six times in the true pelvis, and thirty-three times placed transversely from left to right.'^ The ascending colon and the transverse colon are also but feebly developed in the new-born, short, and do not differ in calibre from the rest of the large bowel. ^ Symington, loc. cit. McClellan, loc. cit. Karnitzky, " Bauchmassage an Kindern," ArcJiiv f. Kinderheilkunde, 1890-1891, Bd. XII. ' Massini Viginro, Fisiologia della infanzia e fanciulezza, Genova, 1886, and Karnitzky, loc. cit. 462 CONSTIPATION IN INFANTS AND CHILDREN Their development is rather slow till in the third month, when they begin to make rapid strides forward. From the Cyclopjedia of the Diseases of Children. (Keating.) Vol. I. Photograph of a recent dissection in which the viscera were held in position by transfixion with pins; from a new-born child. -5, Central tendon of diaphragm; 6, round ligament of liver; 7, right lobe of liver; 8, right kidney; 15, left lobe of liver ; 16, stomach ; 17, sigmoid flexure of colon. The small intestines are removed. ANATOMICAL 463 The caecum in the new-born lies very high, almost Diagram of the Figure. Karnitzky, loc. cit. McClellan, loc. cit. CHAPTER XI MASSAGE Preliminary Considerations Some pgediatrists advise the practice of massage even in the youngest infant, and Karnitzky ^ relates the case of his nephew, whom he thus treated a short time after his birth. I myself do not favor or advise its application until the child is at least six weeks old, and for these reasons : (a) Abdominal massage for constipation is addressed mainly to the muscles of the large bowel, and the main portions of this organ are, as we have seen, but feebly developed at an earlier age ; not much benefit can there- fore be derived therefrom. (&) The very young infant is exceedingly sensitive to the touch, cries quickly, and at the slightest pressure made its abdominal walls are drawn tense, and all our efforts are in vain. (c) The course of treatment here advised for these very young sprouts of humanity gives results so satisfactory, is so simple, and so readily carried out, that resort to more forcible measures is unnecessary. The only exceptions I make to this rule are the cases of hand-fed infants, where marked dyspeptic phenomena 1 Loc. cit. 464 MASSAGE 465 attend the constipation, where the latter seems to be dependent upon the former, and where the question of insufficient development or inefficient action of the special digestive apparatus arises. Here the massage is addressed chiefly to the small intestines after the method described further on. 1. In young infants massage is best made whilst the child is either nursing the breast or taking the bottle ; in this way we may readily obviate its crying, and thereby the drawing tense of the abdominal walls. In older infants (after six months) this precaution is not necessary. 2. All bands around the abdomen and thorax must be loosened. 3. With infants who are easily frightened, uncovering of the abdomen alone may bring on a crying spell that will make massage impossible. Then again, the abdomen being always kept well covered, a sudden exposure of it, especially if it be a cool day, may cause a rapid and strong reaction to the manipulations of the masseur. The whole belly need not be exposed at the time of treatment ; in fact, it need not be uncovered at all if the masseur is expert in the execution of the manoeuvres, and familiar, without sight, with the locality to which the treatment is applied. 4. The amount of the pressure made by the hand will depend upon the degree of tension of the abdominal parietes ; it can be greater when these are more relaxed and less so when they are more tense. It is best to pro- ceed gradually from the very slight and superficial to the greater and more profound pressure. 5. A correct measure of the innocuousness of our 466 CONSTIPATION IN INFANTS AND CHILDREN manipulations are the abdominal walls ; they will remain relaxed and loose if the massage be harmless, as it should be, but will be drawn tense at once if the least pain is inflicted. To attempt to overcome the reaction of the infant to the application, despite the tenseness of the abdominal walls, by the exercise of still greater and more penetrating pressure, would be to commit a grave and serious error. When despite our gentlest and most soothing efforts this reaction, this contraction and rigidity of the abdomi- nal muscles, at once sets in, it is best to abandon massao-e, to give up all idea of its application in such a child. ^ 6. Massage must not be applied more than twice per day. In my own experience I have found that all the good effects can be obtained by one application per day. My practice is to make or have made one application daily for two to three weeks, and then every other day, and lastly^ twice a week for the rest of the requisite period. 7. Each seance (session) must not last more than ten minutes ; usually six minutes suffice. In mild cases a sit- ting of four minutes will be amply long enough. 8. Each seance must begin with a careful, gentle strok- ing of the skin with the well-warmed hand. This proced- ure is absolutely necessary as a sort of preparation for the more forcible movements which are not so readily toler- ated by the little ones ; in fact, it would be impossible to make them if we were to begin with them. In the course of one-half to two minutes the infant is accustomed to the gently stroking hand of the masseur ; 1 Kavnitzky, loc. cit. MASSAGE 467 it does not resist any further ; the abdominal walls remain relaxed, and we can proceed to the massage proper. 9. The skin of young infants is very tender and easily irritated ; various eruptions, as a result thereof, may be called forth or even a serious infection (to which children are very susceptible) produced. To avoid such unpleasant consequences the masseur shall, before beginning treat- ment, cleanse his hands thoroughly with hot water and soap, the nails being well brushed, and then dip them into a solution of boracic acid (or mild bichloride) as hot as can be comfortably borne. They are then thoroughly dried with a well-warmed towel. 10. Karnitzky opposes the anointment of the operating fingers, believing that the manoeuvres cannot be executed as well. Though agreeing with him fully as regards adults, and even older infants, I rather believe it advan- tageous in very young infants as furthering the ease with which the movements are made, lessening the tendency to reflex contraction of the abdominal walls, and as a safe- guard against any undue irritation from friction. As far as I have been able to observe, it does not detract from the effectiveness of the manoeuvres. I therefore advise that for very young infants the fin- gers of the operating hand shall be anointed with vaseline kept especially for this purpose, and used for no other. The parts of the abdomen to be acted upon. In the new-born and very young infants the left side and the lower border of the abdomen from the left to the middle line of the symphysis pubis are the regions mainly to be treated. 468 CONSTIPATION IN INFANTS AND CHILDREN Of the right side, that part lying between the costal arch and the crest of the ileum need not be treated at all ; the region extending from the middle line of the sym- physis pubis to a little distance beyond to the right must be acted upon. The transverse colon it is rather difficult to affect be- cause it is so small, and because of the immediate neigh- borhood of the large liver which frequently covers much of it. In this region much pressure cannot be made with- out immediately exciting vomiting. In infants three or four months old, the left side and the lower boundary of the abdomen to the left are still the principal parts, but the right side has already acquired some importance because the caecum and ascending colon have already considerably developed, especially in hand- fed children. In infants from six months on the whole tract of the large bowel must be covered in the manipulation as in the adult ; it is now the main part to be massaged. In very young infants avoid the umbilicus (so as not to cause any loosening or separation of the parts beneath, and thus produce an umbilical hernia), and do not make any pressure upon the bladder (which, almost always, is more or less full).^ 1 Karnitzky, loc. cit. CHAPTER XII TECHNIC OF MASSAGE FOR INFANTS AND YOUNG CHILDREN In the execution of the various manipulations made with a friction movement, the operating fingers must be held closely to the skin of the infant's belly, so that the fingers and the skin shall move as one and act as one upon the parts beneath. This is of much advantage for the effectiveness of the manoeuvre, and readily guards against any irritation or undue excitation of the infantile cuticle.^ In view of the very considerable length of the mesen- tery in children, and its great mobility, the deeply im- pressed skin should not be moved too far out (in the circles described) from the point of outset of the manoeu- vre ^ (so that there may not be any accidental dislocation of bowel). A most important rule in the massage of infants is this : Never make the pressure so profound or so strong as to cause even the slightest pain. An error thus once made may frustrate all further efforts at treatment on our part, which may succeed at the hands of another and more careful person. 1 Karnitzky, loc. cit. 2 Jbid. 469 470 CONSTIPATION IN INFANTS AND CHILDREN Manipulations Introductory Effleurage. — The operator sits (or stands, whichever is most convenient) to the child's right, with his face to the left. The hand, prepared as already described, is laid upon the child's belly, so that the con- vexity thereof shall lie in the palm of the hand, gently and slowly, so that the infant or child may not be fright- ened and strong reflex contractions of the abdominal parietes be called forth. It is allowed to rest there for a few seconds, then a gentle effleurage, a light stroking movement with the whole palmar surface, a pettmg movement, is made from above downward; when the symphysis pubis, or nearly there, has been reached, the hand is slightly raised, carried back to the point of begin- ning, and the movement is repeated. This manipulation, which is a sort of preparation for the child, need not take more time than a minute or two. It should always precede the massage proper both in infants and children. Manipulation I. — The operator, in the position de- scribed above, places his hands so that the fingers shall reach just beyond the umbilicus (about one centimetre) over on the left side. The index, middle, and ring fingers (if the hand is large, the first two alone will suffice) are flexed somewhat in the second joint, and the pulpy por- tion of the tip set in firm contact with the skin of the belly. The remaining finger or fingers are held extended, and abducted from the others, or they can be closed into the palm of the hand. Beginning at a point about one to one and one-half centimetres from the umbilicus (to the left), light frictions MASSAGE FOR INFANTS AND YOUNG CHILDREN 471 are made, the force of the pressure being gradually in- creased. Moving from one point as a centre larger and more eccentric circles are described by the operating fingers, the force of the pressure increasing with the enlarge- ment of the circle. Then the radius of the circle, and with it the force of the pressure, is diminished, and the fin- gers return to the point of beginning. This manoeuvre is carried out in various directions, the hand and fingers being moved down to the necessary points until the whole left side, from the edge of the tenth rib down to the immedi- ate vicinity of the symphysis pubis, has been gone over.^ Time required, two to three minutes. Manipulation II. — The operator is in the position already described. The hand is laid upon the belly, upon ^ Karnitzky, loc. cit. 472 CONSTIPATION IN INFANTS AND CHILDREN the left side, either obliquely from right to left, so that the tips of the fingers shall be close to the spleen, or straight m a vertical line, fingers jDointing upward to the face. The first fingerl are flexed in the second joint, and the tips rest upon the child's belly. A friction and kneading (petrissage) movement in very small circles ^ is made. The lines of the manoeuvre run from above downward in a ver- tical line. The small intestines and the large bowel (whatever of it is on the left side, but mainly the sigmoid flexure) are acted upon.^ Time required, about two minutes. Manipulation III.— For the lower joart of the descending colon and for the sigmoid flexure. (When practised on young infants, it should always be made with anointed fingers.) The operator is to the right of the child, facing it. He lays his right hand upon the left side of the child's belly, on the lower half thereof, so that the finger-points, ex- tending a little beyond the crest of the ilium upward, lie over that part of the descending colon where it is about to pass into the sigmoid flexure. It is placed in such a way that the ends of the first three fingers only are in close contact with the belly, whilst the rest of the hand rises obliquely therefrom. Now a stroking (effleurage) movement is made down- ward. Then along the crest of the ilium to the symphysis pubis ; here, passing over to the right side, the bladder ^ See Part I., chapter "Massage," page 208. ^ Karnitzky, loc. cit. MASSAGE FOR INFANTS AND YOUNG CIlILUllEN 473 being avoided, the movement is continued for a short distance in this direction. Whilst the movement is essentially one of effleurage, it is nevertheless intended that a certain amount of deep pressure, a sort of kneading or rolling (petrissage) move- ment, shall at the same time be made ; all in such a way that the collected and hardened faeces will be broken up and carried down to the rectum. Karnitzky for the same purposes makes the following manipu- lations: The thumb of the right hand is placed in the right lumbar region on a line with the upper border of the pelvis, and the two middle fingers of the same hand are similarly placed on the left side. After fixation of the skin, as in all preceding manipulations, small circular friction and light kneading move- ments are made on the left side, in the course of which the force of the pressure is gradually raised, the operating fingers being pressed in more profoundly. Moving the finger-tips from point to point, the masseur brings them from upward and 474 CONSTIPATION IN INFANTS AND CHILDREN outward, downward and inward, into the hollow of the lesser pelvis, all irritation of the bladder being thus avoided. Manipulation IV. — (In the execution of this the opera- tor can be to either side or at the feet of the child.) The right hand is placed upon the right side of the child's belly, on the lower part thereof, in such a manner that the points of the first three fingers, flexed at the second joint, shall rest upon the beginning of the caecum in the right inguinal region. A combined friction and petrissage movement is made ; the circles, at first small, are gradually enlarged until they cover the whole width of the caBCum and beyond, and then are again diminished ; without interruption of the circular movement, the fin- gers are carried upward, somewhat outward, and again inward, until the whole caecum and ascending colon to the costal arch have been manipulated. Or it can he made in this wise. — The operator on the left of the child, facing to its right. He lays his hand upon the child's belly, palm down, so that its ulnar bor- der shall touch or slightly cover the right half of the costal arch, whilst the two middle fingers, flexed in their last joint, turn outward toward the upper border of the pelvis, the crest of the ilium, of the same side. Circular frictions are made along the line of the large bowel, downward and outward, upward and downward.^ Manipulation V. — The operator at the feet of the child, facing it. The tips of the operating fingers are placed over the transverse colon on the right side, and the move- ment described in Manipulation IV. made over the whole length of the transverse colon. 1 Kariiitzky, loc. cit. MASSAGE FOR INFANTS AND YOUNG CHILDREN 475 Manipulation VI. — The operator to the right of the child with his face to its feet. The left hand, palm downward, is laid upon the belly in the right lumbar and inguinal regions, so that the tips of the finger, look- ing downward, shall reach almost to the symphysis pubis. The hand is laid so that only the ends of the fingers are in immediate contact with the belly, whilst the rest of the hand is raised obliquely therefrom. The movement, an effleurage, with something of a petrissage, is now made from below, upward along the course of the caecum and the colon ascendens. Manipulation VII. : Contmuation of VI. — The operator now turns around and faces the child. The operating fingers are placed, in the manner already described, over the beginning of the transverse colon on the right side, and with the same effieurage movement are carried over to the left side, to the spleen. Manipulation VIII. : Continuation of YII. — Same as Manipulation III., with this difference, that the point of outset for Manipulation VII. is from beneath the lower border of the twelfth rib, over about the point of begin- ning of the descending colon. ^ Manipulation IX. — The operator stands to the left of the child. The thumb of the right hand is placed upon the right side of the child's belly, on the lower part thereof, about the beginning of the caecum, the. radial surface of the thumb in contact with the skin of the belly. From here it is carried with a combined effleurage and petrissage movement over the caecum, colon ascendens, 1 See Part I., page 226, Manipulation 3, a, b, c. 476 CONSTIPATION IN INFANTS AND CHILDREN transverse colon, descending colon, and sigmoid flexure to the beginning of the rectum. By this movement faecal accumulations and indurations are broken down and carried upward and over and down- ward ; the intestinal parietes are stimulated and aroused to more energetic action. Thus, all the good effects of massage are realized from it. Manipulation X. (rather irritating to young infants ; especially applicable to very obstinate cases). — The operator stands to the right of the child, facing its feet. The left hand is placed upon the abdomen in the inguinal region in this way that the tips of the fingers (the first three ; little finger abducted) shall rest about over the beginning of the caecum. Then a short, quick, effleurage movement is made that carries the fingers forward, but raises them from the skin after they have travelled a short distance, after the manner of the carpenter's plane. Then the fingers are replaced about the mid- MASSAGE FOR INFANTS AND YOUNG CHILDREN 477 die of the region travelled over, and the movement is repeated. This movement is continued until the whole caecum and ascending colon have been acted upon. Then the operator faces around ; the fingers of the right hand are placed, in the manner described, upon the left side, so that the tips are just at the border of the twelfth rib ; the same manipulation as already just described is made from above downward until the whole descending colon and sigmoid flexure are gone over. Karnitzky also makes tcqootemeiit in children over a year old, beating or clapping the belly. I do not find this at all necessary. If the manipulation is practised at all in children, it should be made with the hand partially flexed, and holding an air-cushion as it were, as described in Part I., chapter on " Massage," Group E. Punctation is not to be practised on infants and young children ; they bear it badly. Application. In the early part of the infantile life, up to four months, massage of the transverse colon should not be made for the reason, already set forth elsewhere, of the immediate neighbor- hood of the stomach, and because, being covered in great part by the very large liver, it cannot be readily reached. For the new-born, i.e. infants a few days old. on whom it is desired to practise massage for any of the reasons mentioned, to the age of six weeks : (a) Introductory el^eurage. (5) Manipulation I. — mainly. Manipulation II. (in children under three weeks this can be omitted). 478 CONSTIPATION IN INFANTS AND CHILDREN For infants from six weeks to four months old : (a) Introductory effieurage. (fi) Manipulation I. (c) Manipulation II, (c?) Manipulation III. Close with (a). For infants from four to ten months : In the earlier period, — (ci) Introductory effleurage. (6) Manipulation I. (c) Manipulation IV. (d) Manipulation III. Close with (a). In the later period, — (a) Introductory eiSeurage. (6) Manipulation I. (c) Manipulation IV. (cZ) Manipulation VI. (e) Manipulation VII. (/) Manipulation VIII. From ten months to two and one-half years : (a) Introductory effleurage. (5) Manipulation IV. (c) Manipulation VI. , . [ (5) Manipulation IX. Manipulation VIL a^ternatmg with | Manipulation X. (g) Manipulation VIII. - From two and one-half years on : (a) Introductory effleurage. (5) Manipulation II. (c) Manipulation IV. (dT) Manipulation V. (e) Manipulations VI., VII., VIII., alternate with Manipulations IX., X. Close with (a). MASSAGE FOR INFANTS AND YOUNG CHILDREN 479 In children over three years old, tapotement, beating of the belly (with the hand partly closed, so as to hold an air-cushion, as already described), may be made as a closing movement. Where, for any reason, the massage must be made by the mother or nurse, I teach her : For young infants For infants a year old and for young children (a) Introductory effleurage. (5) Manipulation I. ((?) Manipulation II. (a) Introductory effleurage. (5) Manipulation IX. (of first importance). (c) Manipulation X. Older Children As regards older children, from the age of eight years and upward, we will be governed as to the manipu- lations to be practised in their treatment by massage, by the state of their physical development. In the strong and robust the manipulations made in adults will be employed, whilst for the loeak and poorly developed the movements just described for younger children will be selected. CHAPTER XIII SPASTIC CONSTIPATION The nature and cliaracter of spasmodic constipation have already been fully set forth in a previous chapter. Fleiner, who more particularly called attention to this form of constipation, reports also the cases of children thus affected. It is the same in children as in adults, and manifests itself by the same symptoms. The treatment has already been given in detail. It need hardly be said here that if belladonna is prescribed, it must be directed in doses appropriate to the age of the child. As to what the dose should be, writers vary considerably. Whilst some obtain very satisfactory results with small doses, others have found that, most frequently, only full doses produce the desired effect. Ringer ^ has prescribed as much as ten and even twenty minims of the tincture (English) three times daily for children with incontinentia urinse, and Phillips has done likewise. 2 I myself believe, from careful observations, that not infrequently very good results are obtained with very small doses regularly administered at sufficiently frequent intervals. As a rule the dose will be : Of the Extract, from grain ^ to ^, three to four times daily. Of the Tincture, from "l iv to x, three times daily. 1 S. Ringer, Handbook of Therapeutics. 2 Materia Medica and Therapeutics. 480 SPASTIC CONSTIPATION 481 The extract can be prescribed in a fluid mixture ; thus 5 Extract. Belladonna. gr. |-1 Syrup. Rub. Id. aut Syr. Rhei Aromat. § i Aq. Destill. §ii M. Sig. 1 teaspoonful 3 to 4 times daily. Fleiner has obtained the best results with the oil clyster. Treatment of Fissure of the Anus To treat the fissure of the anus is to treat the constipa- tion dependent upon it. The treatment will depend upon the question whether' the pathological condition that confronts us is really an . "irritable ulcer" of the anus, or whether it is a mere fissure or crack that does not involve the sphincter. The irritable ulcer is the form generally seen in children. The most appropriate treatment is "forcible dilatation." This is readily applied, and gives immediate relief. The procedure is very brief for young children, and does not require the administration of an ansesthetic. It is done in this wise : The child is laid on its back upon a high couch or table, or it is placed upon the knees of the mother or nurse on its belly, with its thighs hanging down. The physician introduces, carefully, into the anus the index- finger or thumb of one hand, then of the other hand, the fingers being back to back, as already described, and stretches the sphincter fully and quickly; a grating, crunching noise is sometimes heard ' when this has been' accomplished. 1 Jacobi, Intestinal Diseases of Infancy and Childhood. 482 CONSTIPATION IN INFANTS AND CHILDREN Fissures or cracks are most usually seen in young infants/ and are generally associated with redness and excoriation of the integument immediately surrounding the anus. They are readily visible when the nates are fairly separated. These fissures or cracks occasionally get well without any treatment ; generally we can bring about a cure without any resort to forcible measures, simply by local applications. According to Wharton/ even true irritable ulcer in the young infant can be suc- cessfully so treated. To fissures or cracks a solution of silver nitrate, twenty grains to the ounce (of water), is applied with a brush, or with the applicator and cotton-wool, until a white film forms on the surface. Van Buren has always succeeded with a solution ten grains to the ounce (of water). The irritable ulcer of the young infant will be touched with the solid stick. The parts are then dusted with aristol or dermatol. Some recommend the application of an ointment of iodo- form, but the odor of this is suggestive of so many things and so abhorrent to most people that I do not advise it, especially as we can accomplish all the desired good with the benzoated ointment of the oxide of zinc.^ Furthermore, to hasten the healing we must see to it that the faecal discharges are soft. To accomplish this, we may resort to various medicines administered internally (see "Formulary"), or to rectal injections. Van Buren advises, as the best measure known to him, an enema of 1 Van Buren, loc. cit. 2 American System of Diseases of Children, edited by Starr. 8 Van Buren, loc. cit. SPASTIC CONSTIPATION 483 warm, even hot, water just preceding each stool, with the addition of melted vaseline or sweet oil just before the tube is withdrawn.^ T direct the daily injection into the rectum of 3 ii-5 ss of the best olive oil. For this purpose I find that a hard rubber syringe, of an ounce or two capacity, is the best. In addition, the various dietary articles that tend to loosen the bowels, as stewed prunes, prune juice, prune paste, molasses, syrup, etc., are ordered for the child. After defecation the parts must be carefully cleansed ; absorbent cotton (not sponge, or diaper, or other cloth) and a mild solution of boracic acid are to be used. A careful compliance with these directions will be fol- lowed by a rapid cure. ^ Van Buren, loc. cit. CHAPTER XIV FORMULARY Laxatives for the Youngest Infants 1 Manna, crystalliz. 10.00 (=3 viii) Aq. fervid. 100.00 (= 3iiss) M. Sig. In tablespoonful doses. I},^ Manna. Optim. 3ii Aq. Anethi 5i M. Sig. Teaspoonful (3i) doses. Manna. Optim. 3ii Syr. Rosar. S i M. Sig. Teaspoonful (3i) doses. 5 Syr. Manna. 3vi Syr. Rhei Aromat. 3iii M. Sig. In doses of 3 ss-i. For somewhat older infants (after second or third month) 5. ^ Magnesia. Carbon. 3 i Manna. Optim. 3 ii Tinct. Rhei C0.5 31 Syr. Rosar. ad S iss M. Sig. In doses of 3 i-ii. '1 Gerhard, Handbuch der Kinderkr., loc cit. 2 Ellis, Diseases of Children. 8 Ibid. ■* Ellis, loc. cit. « Tinct. Rhei can be used instead. 484 FORMULARY •485 Magnesia. Usta. Syr. Rhei Aromat. Syr. Rosar. 3 1-11 §ss ss M. Sig. In teaspoonful (3 i) doses. For infants (from six months on) and young children : Pulvis Puerorum Hensleri,^ Pulvis Rhei Co. Sapo. Medicata. Magnes. Carbon. Rhei rad. pulv. M. triturat. bene et ft. pulv. Sig. Dose, iive to fifteen grains. 3 Pulvis puerorum Hufelandi, Pulvis pro Infantum Hufe- landi.2 Sacchar. Alb. Ole. Foenicul. ^Eth. aa 60 parts 1 part 5. INIagnesia. Carbon. 15 parts 20 parts 10 parts 5 parts 1 part 15 parts Rad. Glycerrhiza. Rad. Rhei pulv. Valerian. Rad. Croci Semin. Anis. M. triturat. bene et ft. pulv. Sig. Dose, five to fifteen grains. Podophyllin grs. viii^ Iridin. grs. v Spirit. Amnion. Aromat. Si Digest for several days and then filter. Sig. Dose, one or two drops on a piece of sugar or mixed with any syrup. For a child a year old. ^ Strumpf, AUgemeine Pharmakopoe. Strumpf, loc. cit. 8 New York Medical Record, May 7, 1887. 486 CONSTIPATION IN INFANTS AND CHILDREN 5 Podophyllin gr. i Spirit. Vin. Rectif. 3 iss Syrup. Altha. ad § iv M. Sig, A half-teaspoonful daily. 1 For Children 5 Fruct. Tamarindi Sig. 3 ii at a dose. 5 Mannse 3 vi ^ Magnes. Carbon. Sulph. loti aa § iss Mellis f 3 vi M. Sig. Dose, one-half to two teaspoonfuls according to age. 5 Infus. Laxativ. Viennens. Syr. Rhei Aromat. aa i i M. Sig. One teaspoonful every three hours. For a child two and one-half years old. Pleasant and effective. Soda. Phosphat. § i ^ Syr. Limon. § ss Decoct. Hordei S vi M. Sig. Dose, two tablespoouf uls. A pleasant aperient. 5 Magnesia. Sulphat. 3 ii* Acid. Sulphur, dilut. gtt. v Syr. Aurantii 3 iii Aq. Carui 3 v M. Sig. 3 ii every hour till bowels act. A more active purge. For a child three years old. 1 Bouchut, E., also in Wilson, Complete Medical Pocket Formulary. 2 Ferraud, Wilson, Complete Medical Pocket Formulary. 8 Ellis, loc. cit. * West, Diseases of Children. FORMULARY 487 Emulsion of castor oil (Trousseau) ^ Ole. Ricini § i Vitel Ovi semissem (i) Tere simul et adde Aq. Flor. Aurant. Syr. Simpl. aa § i Aq. Destill. aut B'oenicul. § vi^ M. ft. Emulsio. s. a. Sig. § i at a dose. Alterative Aperient : Mass. pillul. Hydrarg. grs. i-ii Syr. Rhei Aromat. § i M. Sig. 3 i every two to three hours till bowels move (or till stool is changed in appearance). Oatmeal Water First prepare an oatmeal porridge ; take a heaping teaspoon- ful of this, put into a quart of cool water, heat with constant stirring to the boiling-point, and strain. ^ Take a large tablespoonful of fine oatmeal, put into a sauce- pan with a quart of water, allow it to boil down to three-fourths of a quart. Strain. Soap Suppository- Must vary in strength according to the age. For a child of two months, one grain of soap with ten grains of Oleum Theohrom. will be sufficiently strong ; at one year, five grains of soap can be put into the suppository. Or in place of the suppository we may use the soap stick ; commonly, the ordinary brown soap is used for this purpose. Starr directs that Castile soap be employed. It is prepared 1 Clinical Lectures. 2 For other formula for emulsions, see " National Formulary." 8 Starr, Hygiene of the Nurseiy, 488 CONSTIPATlOxN IN INFANTS AND CHILDREN thus: Cut from a bar of good Castile soap a piece two inches long and halt an uach thick. Scrape this into a cone, pointing one end like a sharpened pencil, but with a blunter point and more gradual slope ; make it quite smooth by rubbing the sur- face with a wet rag. When the soap stick is to be used, anoint the pointed end with vaseline, and gently insert into the rectum untd the sphincter closes over it.i ^ Starr, loc. cit. INDEX Accumulation, enormous, of fteces, Case 25, 148. Adulterated, articles of food, 102. Adulterations, 200. Age, old, 101. Ammonium chloride, 304. Anal fissure, 135, 419. Anus, excoriation of, 419. fissure of, 343. malformation of, 387. Appendicitis, causation of, 136. Appendix vermiformis, 10. orifice of, 10. Arch, transverse, 11. Arteris : arteria sigmoidea, 19, colica dextra, 19. colica media, 19. colica sinistra, 19. external hsemorrhoidal, 20. hsemorrhoidal superior, 20. ileo-colic, 19. inferior mesenteric, 19. inferior pancreatico-duodenal, 19. middle hfemorrhoidal, 20. pancreatico-duodenalis, 18. superior mesenteric, 18. vasa intestini tenuis, 19. Atony, of the intestines, 94. causes of, 95. of the intestine, in chlorosis, 104. of the intestine, as a sequel of in- fectious diseases, 104. of the intestine, symptomatology, 105. of the intestine, symptoms, gen- eral, 106. of the intestine, symptoms, local, 109. of the pouch of the rectum, treat- ment of, 311. of the stomach, 173. with enterospasm, 90. Atrophy, essential primary, of the large bowel, 79. Atzperger's apparatus, 337. Auto-intoxication, 173. B Bandages, belts, for relaxed abdominal walls, 201. hsemorrhoidal, 349. Basedowii Morbus, 179. Bath, cold-tub, 270. Bauchpresse, 37. Bauhini valvula, 9. Bauhinian valve (can be passed by fluids injected into the rectum), 55. Bergeon (rectal injection of sulphu- retted hydrogen), 107. Bicycle riding, 197. Boracic acid, application of, in consti- pation, 360. Borborygmi, 183. Bougies, rectal, for dilatation, 361. Bowels, atony of, 94. large, 7. large, division of, 9. in young infants, 461. Cfecum, 9. Carbonic acid, for painful conditions of rectum, 339. 489 490 INDEX Catarrh, chronic, o£ the intestine, treat- ment of chronic constipation caused by, 317. Charcot-Leyden crystals, 128. Chlorosis, 104-183. Cincture-feeling in enterospasm, 90. Clysters, 2G4. Colics, treatment of, without narcotics or liquor, 447. Colon, ascending, 10. congenital obstruction of, 395. descending, V2. malplacement of, 397. transverse, 11. Compress, cold, abdominal (Neptune's girdle), 275. Complications, 306. Concretions, 139. Case 20. Intestinal concretion, 144. Case 22. Concretion of chaff of oats, 146. Case 23. Concretion of iron and magnesia, 147. Case 24. Concretion of sawdust, 148. Confectio sennse, 372. Constipation, classification of, 42. definition of, 42. etiological factors, 42. acute, causes of, 46. acute, causes of, in children, 412. acute, definition of, 43. acute, treatment of, 416. atonic, 94. atonic, causes of, 95. atonic, diagnosis of, 112. atonic, diagnosis of, in children, 437. chronic, causes of, 57. chronic, causes of, in children, 418. chronic, definition of, 43. chronic, from impaired physio- logical functioning, 86. congenital, 62, 387. congenital, treatment of, 416. habitual, 86. habitual, in infants, causes of, 423. habitual, in older children, causes of, 434. hysterical, case of, 52. in old people, treatment of, 365. of the insane, 93. of the insane, treatment of, 93. spastic, 87. spastic, treatment of, 324. spastic, treatment of, in children, 480. Contra-indications to massage, 260. Corde colique transverse, 84. Cough, irritating, 180. Cow's milk, feeding with, 425-442. Crises enteriques, 88. Cushion, Feilchenfeld's, 241. D Debility from protracted maladies, cause of chronic constipation, treatment of, 322. Defecation, 35. Diagnosis of atonic constipation, 112. of atonic constipation, in chil- dren, 437. Diaphragms, 78. cases of, 78, 79. in the small intestines, 406. cases of, 406, 407. Case 67, diaphragm at one point and a stricture at another, 407. treatment of, 409. Case 58, illustrating treatment of, 409. Diarrhoea with constipation, 166. Case 35, 167. with obstruction, 169. case of, 169. Diet, dietary regulations, 187. Dietetic exercise, 193. preparations, 378. Dilatation, of the large bowel, 150. of the large bowel, in children, 429. INDEX 491 forcible, of the sphincter of the anus, 331. gradual, of the sphincter of the anus, 360. gradual, of the sphincter of the anus, instruments therefor, 861. Dislocation, of the bowel, 80. of the sigmoid flexure, 84. Diverticula, 72, 160. false, of large bowel, 163. of the small intestines, 164. Case of diverticulum of ileum, 165. Diverticulum, congenital, of sigmoid flexure, 72. Douche (shower bath), 277. Drink, 192. Drugging of infants, 424. Duodenum, 3. Duodenum, division of, 4. Duration of treatment (massage) , 239. E Effleurage, 206. introductory, 237. Electricity, 283. faradic current, 285. franklinization, 294. franklinization, in hysteria, 297. galvanic current, 291. galvano-faradization, 293. general faradization, 294. scheme of electrical treatment, 297. selection of current, special indi- cations, 297. effect upon intestinal secretion, 297. in young children, 457. Electrodes, rectal, 289. Electuarium lenitivum (Wintheri), 372. Mannas, 372. Enemata, 264. for infants, fluids for, 451. for infants, instruments for, 449. how to administer in infants, 450. Enteritis Membranacea, 138. Enteroliths, 139. Case 21, removal of, 145. Enteroptosis, 80. Enterospasm, 87. treatment of, 324. Enterospasm and atony, 90. Ergot, 302. Exercise, 193. lack of, 99. F Fsecal vomiting, 29. Faeces, appearance of, 39. color of, 40. composition of, 39. constituent elements of, 40. microscopical appearance of, 41. microscopical exam, of, 41, 127. reaction, 40. Fats, deficiency in, 98. Feeding, artificial, regulations for, 445. breast-feeding, rules for, 444. improper, 425-443. Feilchenf eld's cushion, 241. Fissure, anal, in infants, 419. Fissure of the anus, 135. treatment of, 343-481. Flatulence, 109. Flatus, 27. accumulation of, 29. action of, 29. mode of discharge, 29. recognition of, 29. Flexura coli dextra seu hepatica, 11. Flexura coli sinistra seu linealis, 11. Flexure, left colic, 11. right colic, 11. sigmoid, 12. Foods, deficient in fats, 98. deficient in residual matters, 97. Force pump, 267. Foreign bodies, classification of, 46. sharp, swallowed, 47. sharp, swallowed, treatment for, 47, 48. Case 1, swallowing of open pen- knife, 47. 492 INDEX Case 2, swallowing of a plate with teeth, 48. Case 3, glass syringe broken off in rectum, 49. Case 4, piece of wood driven into rectum, 50. Case 6, swallowing of hair, 60. Formulary, 369. for infants and young children, 484. Franklinization, 294. in hysteria, 297. Frequency of treatment (massage), 239. Frictions, 207. G Gall-stone, as a cause of acute consti- pation, 416. Gases, development of various, 28. groups of, that constitute the flatus, 27. volume of, 28. Genital organs, diseases of the, 182. Genito-urinary diseases, constipation from, treatment of, 340. Girdle, Neptune's, 215. Gravel, river (Flusskiesel), in treat- ment of constipation, 363. Groin, pain in, 182. Gymnasium, pocket, Goodyear's, 261. H Habitual constipation, 86, 422. Hsematine, 127. Hgematoidin, 127. Hfemicrania, 177. Hferaorrhoidal bandage, 349. tumors, injection of, formula for, 377. veins, 133. Haemorrhoids, mode of production of, 132. non-surgical treatment of, 345. Halbbad, 270. Heart, palpitation of, 176. Horseback riding, 197. Hydrogen sulphide, in stomach, 27. Hydrotherapy, 264. I Ileum, 6. Ileus, mechanical, 170. mechanical, treatment of, 308. paralyticus, 170. Infants, drugging of, 424. Inflation, of large bowel, 123. Injection, formula for, of hsemorrhoidal tumors, 377. Injections, hot, 55. large, 55. of oil, 353. rectal, 270. rectal, in jaundice, 270. Injury, traumatic, of small intestines, causing acute constipation, 413. traumatic, of small intestines, caus- ing acute constipation, case of, 413. Insomnia, 181. Intestinal concretion, voluminous, case of, 61. paralysis, treatment of, 310. Intestines, disconnection of the whole digestive tract, case, 404. division of, 3. large, malformations of, 62. case of abnormally developed colon, 63. case of enormous development of colon, 65. case of enormous development of sigmoid flexure, 70. case of undue size of sigmoid flexure, 69. small, 3. small, length of, 3. small, malformation of, 398. Intestinum crassum sen amplum, 7. Introductory effleurage, 237. Itching at the anus, 110. J Jaundice, 171. Case 37, 171. Case 38, 172. Jejunum, 6. INDEX 493 K Kahn's roller, 241. Kammgrlff, 217. Kinesipathy (Swedish movement cure), 243. L Levator ani muscle, action of, 38. Linea interspinalis, 119. Linea spino-umbilicalis, 119. Liver, in infants, 460. torpid, 170. M Machine gymnastics, 259. movement cure, 259. Malformations, of the anus and rectum, 387. of the anus and rectum, synoptic table of, 392. of the colon, 393. of the small intestines, 398. Case 46, congenital obliteration of, 398. Case 47, congenital obliteration of, 399. Case 48, imperforate ileum, 401. Case 49, imperforate ileum, 402. Case 50, no connection be- tween the small intestines and the large bowel, 403. Case 51, no connection be- tween the small intestines and the large bowel, 403. Malplacement of the colon, 397. Manipulations, 214. schedule of, 238. for infants, schedule of, 477. Massage, 203. technic of, 206. abdominal, 211. abdominal, rules for, 211. abdominal, operative technic of, 213. contraindications to, 260. in infants, 452. in infants, rules for, 464. in infants, technic of, 469. in infants and children, manipu- lations of, 470. instrumental, 240. Medicines, 299. Mental work, mental worry, cause of constipation, 101. Mesocolon, transverse, 11. Mesorectum, 13. Morbus Basedowii, 179. Movements, active, 245. against resistance, 249. passive, 256. Mucus in stool, 127. N Neglect of the call of nature, 95. Neptune's girdle, 275. Nerves, of the intestinal tract, 21. the inferior haemorrhoidal, 24. the superficial perineal, posterior branch of, 24. the cutaneous (from fourth sacral) , 24. Nervous system, functional disturb- ances of, 176. Neuralgia, lumbo-abdominal, 180. trigeminal, 177. Neurasthenia, constipation caused by, treatment of, 319. Noises in the abdomen, 183. Nux vomica, strychnine, 299. 0 Oatmeal water, 487. Obesity, 101. OEdema, 159. Oil, how warmed, 354. injections of, 353. injections, technic of, 354. injections, tip for syringe for, 355. Ointment, for haemorrhoids, 375. for rectal pain, 375. Old age, 101. 494 INDEX Old people, constipation of, treatment, 369. Otalgia, from constipation, 180. Overalgia, 181. P Pain in enterospasm, 89. Palpation of large bowel, 116. Paralysis, of intestine, treament of, 310. Particles, coarse, action of, 33. Percussion of large bowel, 117. Peristaltic movements, visible upon the abdominal walls, 126. Peristalsis, intestinal, 30. influence of carbonic acid on, 34. influence of oxygenation on, 34. influence of venous stasis on, 34. of the large bowel, 32. of the small intestines, 31. Peritonitis, tubercular, 420. case of, 420. Petrissage, 208. Physostigma, physostigmatis faba, 301. Plaetschern (splashing), in bowel, 130. Plexus, aortic, 22. hypogastric, 22. inferior mesenteric, 22. myentericus of Auerbach, 21. of Meissner, 21. solar, 21. solar, vibration of, 2-32. superior mesenteric, 22. Plica sigmoidea, 16. transversalis recti, 16. Proctitis, 138. Prognosis of habitual constipation, 131. Psychoses, 181. Psychrophor, 341. Pump, force, 267. Punctation, 218. Pus, 127. K Eeading at stool, 96. Rectum, 13. and anus, malformations of, 387. Case 40, complete closure of the rectum, 388. case of sloughing of, 138. distention of, 155. irritable (hysterical), treatment of, 333. spasmodic stricture of, 90. Relaxation of abdominal walls, 200. Restaurateur of Sachs, 261. Riding, bicycle, 197. horseback, 197. in a vehicle, 197. River gravel, in treatment of constipa- tion, 363. Roller, Kahn's, 241. Rowing, 197. apparatus of Ewer, 261. apparatus of Sachs, 261. Rubbing, cold moist, 273. Rules, for abdominal massage, 211. for exercise, 198. for kinesipathy, 245. for walking, 196. of conduct, 185. S Sacculated appearance of large bowel, 15. Sacculi Horneri, 18. Schedules of manipulations, 238. of manipulations, for infants, etc., 477. Sciatica, 181. Senator, hydrothionamie, 107. Sennse, confectio, 372. Shower bath, 277. Sigmoid flexure, 12. dragging down of, 154. Soap, suppository, 487. stick, 487. Solar plexus, vibration of, 232. Sounds, heard on palpation of bowel, 120. Spasm, of intestinal muscles, general, partial, 87. of the sphincter ani (without local lesion), treatment of, 330. INDEX 495 Spasmodic stricture of the rectum, 90. treatment of, 329. Spastic constipation, 87. Spermatic cord, pain in, 182. Spliincter, O'Beirne's, 35. spinal centre of, 36. Sphincter of the anus, 14. external, internal, third, 14. irritable, 91. spasmodic contraction of, 91. Splashing (plaetschern), heard in bowels, 130. heard in left colic flexure, 121. Stomach, atony of, 173. in infants, 458. Stretching of the sphincter ani, for constipation, 359. Stricture of the intestine, congenital, 404. Case 53, of duodenum, 404. Case 54, of duodenum, 405. of the intestine, diagnosis of, 115, 124. of the intestine, interstitial, fre- quency of, 116. of the intestine, tuberculous, 113. Suggestion, treatment by, 364. Sulphuretted hydrogen, rectal injec- tion of, 107. Suppositories for haemorrhoids, 37G. Swedish movement cure (kinesi- pathy), 243. Symptomatology of atonic constipa- tion, 105. of atonic constipation in children, 437. T Table of temperatures of water (defi- nition of the various expres- sions, warm, hot, etc.), 282. Tsenise, of the large bowel, 10, Tapotement, 209. Teeth, bad, 101, want of, 101, Temperature of water for clysters, 266, 451. Testicle, pain in, 182. Tic douloureux, 177. case of, 178. Tonsil, lingual, enlargement of, 182. Treatment, effects of, 305. frequency of (massage), 239. of constipation due to atony, 185. of constipation due to atony, in infants, 440. of constipation due to atony, in older children, 455. of conditions related to atony, 308. of constipation dependent upon genito-urinary troubles, 340. of relaxed abdominal walls, 201. Tumors, fsecal, 139. Case 16, mistaken for nephritis, 140. Case 17, mistaken for organic tumor, 141. Case 18, mistaken for malignant disease of the liver, 141. Case 19, mistaken for wandering kidney, 142. abdominal, diagnosis of, 123. Typhlitis, 136. U Ulcer, irritable, 135. Ulcers, by distention, 159. V Valve, ileo-c3ecal, 9. Valves of the rectum, 16. Varicocele, 159. Veins, 20. W Walking, 193. Wash, for haemorrhoids, 377. Water, cold, abstaining from, 99. cold, effects on intestinal canal, 99. Winternitz, device for applying cold to the rectum, 338. Worms, as a cause of acute constipa- tion, 410. Z Zander institute, 259. Zinc sulphate, 302.