Constipation (see)

Constipation, see Dipsomania. CONSTIPATION. Contents: Etiology and pathogenesis..............482 Clinical picture..............489 Diagnosis.....................482 Prevention..................482 Treatment....................493 Constipation in children..................497 Constipation (obstipatio alvi), prolonged retention of feces in the intestine, caused by delayed elimination of waste from the body. In diagnosing constipation, it must first be borne in mind that the widely held opinion that a person must necessarily defecate only once a day is not entirely correct. The frequency of defecation depends primarily on constitutional peculiarities of the body, which are often inherited; thus, there are families where most members normally have bowel movements every 1-2 days, while in other families, two bowel movements a day should be considered completely normal. An even greater influence on the frequency of bowel movements has the person's lifestyle, and above all, the nature of their food; thus, with complete abstinence from food, bowel movements appear after 5-6 days, with a strict meat and egg diet-after 2-3 days, with a purely meat diet-with a small amount of plant food-after 1-2 days, with a mixed ordinary diet (¹/₃ meat and ²/₃ plant food-bread, vegetables, fruits)-daily once, with a purely plant diet-1-2 times a day. Living conditions, dietary regimen, conditions of cultural life in connection with conditioned reflexes developed through education establish in the urban dweller the appearance of bowel movements usually daily at a time fixed forever. Thus, the concept of constipation is not absolute, but relative and should be evaluated only in connection with the past life of this person, for which reason great symptomatic significance is attached to suddenly appearing constipations, especially if they are not associated with a change in diet or with a change in lifestyle (e.g., with train travel). The passage of food through the intestine and the formation of feces represent a very complex process, studied mainly by applying new experimental research methods, e.g., radiodiagnosis (Stierlin, Schwarz and others), the "abdominal window" method (Katsch). No less complex is the act of defecation itself. Both of these processes-the passage of feces through the large intestine and defecation-are subject, besides the mechanical irritation of the intestine by its contents (solid, liquid and gaseous), to a very complex autonomic nervous apparatus on the one hand, to the influence of the peripheral nervous system (musculature of the perineum and abdominal press)-on the other, and finally to the very strong influence of the psyche. The complexity of the physiological process of formation of feces and defecation explains the very diverse mechanism of pathophysiological phenomena observed in constipation, why their final result-retention of feces-should be considered only as a symptom, having a very different pathogenesis and being the result of extremely diverse etiological factors. The entire difficulty of diagnosing constipation in each individual case consists in establishing its etiology and pathogenesis in this patient and hence-in the need for individual and very different each time prevention and therapy of constipation. Etiology and pathogenesis of constipation. It is advisable to distinguish constipations that are only a symptom of this or that organic disease of the intestine, from constipations as a result of functional pathophysiological processes occurring without visible anatomical substrate. However, it must be borne in mind that a strict separation of these two varieties of constipation is practically not always possible, and often anatomical causes located in the abdominal cavity, although outside the intestine (e.g., disease of the appendages of the uterus, urinary apparatus, cholecystitis, pyelitis), reflexively cause functional changes in the dynamics of the intestine, as a result of which constipations appear. To organic or symptomatic constipations (obstipatio alvi symptomatica) belong constipations as a result of constitutional changes of the intestine, mechanical constipations and inflammatory constipations. 1. Of constitutional changes of the intestine leading to constipation, one should have in mind changes in length, position and lumen of the large intestines; to this group also belong constipations of apparently functional character, sometimes appearing in patients with constitutional splanchnoptosis in asthenia universalis congenita, where besides the doubtful influence of the prolapsed intestine plays a role the dissociation between the work of the abdominal press and the work of the intestine during defecation (A. F. Hertz, Katsch). From this group of constipations the most pronounced are cases of prolonged constipation in megacolon congenitum (see Hirschsprung's disease), when they continue for 10 days or several weeks and even up to 4 months (Luria). However, even with considerable expansion of the intestines, the appearance of a normal daily stool is possible. 2. Of great practical importance are constipations in narrowings of the intestine and obstruction of the intestines of various origins (see Intestine). Regarding them, it should be said that sudden sharp changes in the type of defecations in the sense of constipation without any visible cause should always attract the serious attention of the physician and compel him to resort to special methods of investigation of the intestines (radioscopy, rectoscopy), in order to promptly establish serious organic diseases, most often tumors, ulcers, etc. Whether anomalies of the length of the intestine (especially-flexurae sigmoideae) and the frequently occurring prolapse of the intestines in splanchnoptosis have a direct influence on the appearance of constipations is still an open question. In any case, one often has to see considerable prolapse of the entire intestine with completely normal functions of it. 3. To the number of symptomatic constipations belong also constipations as a result of inflammatory processes of the intestine, especially if the serous covering of the intestines (pericolitis) is involved in the process or if as a result of it adhesions of individual parts of the intestine have appeared, mainly of the large intestine in the region of flexura coli dextrae, and especially sinistrae. However, it must be said that the significance of adhesions of the intestines in the pathogenesis of constipations is somewhat exaggerated (Raug) and often they are the cause not of gross mechanical, but of functional constipations, sometimes then not having any influence whatsoever on the dynamics of the intestine. Clinical picture, differential diagnosis, prevention and therapy of symptomatic constipation are determined by the basic disease of the intestine that caused these types of constipation. Much more common (and therefore has much greater practical importance) is the second group of constipations, where the retention of feces in the intestine is not a symptom, but almost the entire content of the clinical picture as a result of purely functional disorders of the dynamics of the intestine. These functional diseases of the intestine are known under the general name of habitual constipation (obstipatio habitualis). It is completely incorrect to speak of habitual constipation as a single clinical form. In the complex and long chain of physiological processes accompanying the formation of feces, their movement through the intestine and excretion from the body, each link, going beyond the limits of normal function, can become a cause of constipation, and therefore both pathogenetically and etiologically the group of functional constipations breaks down into a number of varieties and separate forms, without correct recognition of which in each individual case one cannot count on successful treatment of constipation. To the group of functional constipations should be attributed the following forms: 1) alimentary constipations, 2) dyskinetic constipations, 3) constipations of endocrine origin, 4) toxic constipations, 5) reflex constipations, 6) constipations in organic diseases of the central nervous system, 7) psychoneurotic constipations and 8) constipations as a professional disease. Of course, mixed forms of functional constipations are also very often encountered, pathogenetically belonging to several forms simultaneously. To the present time we are still far from understanding all the pathophysiological processes underlying functional constipations in each individual case, for which reason there is as yet no generally accepted classification of them. 1. Alimentary constipations (Boas), or false constipations (Noorden) belong to the most frequent forms of functional disorder of the dynamics of the intestine. Although the movements of the intestine depend both on specific hormonal influences (Zülzer) and on the purely automatic muscular elements of the intestine (Magnus), still the decisive significance for the formation of feces, their movement in the intestine and excretion from the body has the composition of food, both qualitative and quantitative. Therefore, the absence of a normal stimulus with a diet meager in quantity and poor in residues usually causes constipation. Precisely to this group belong constipations in the so-called "strict" diet, consisting of broth, chopped tender meat (chicken cutlets), crackers, semolina or rice porridge, etc., often prescribed for a long period by physicians or, which more often happens, chosen by the patients themselves, having misunderstood the doctor's prescription or being afraid to eat due to false ideas about their illness. To this group also belong constipations in the very widespread, rich in proteins and poor in slag meat dietetic regime.

This form of alimentary, or false, constipation has no prerequisites in the pathophysiological processes of the intestine of a given patient and should therefore be considered an artificial disease, very often iatrogenic, and therefore easily treated with proper recognition and elimination of errors, specifically the so-called 'strict' diet, which is why familiarity with this form is especially important for the practicing physician. 2. Dyskinetic constipations constitute the main, most common form of habitual constipations. Here we are dealing with a functional disturbance of the dynamics of the intestine from causes lying within the intestine itself. If in former times the causes of this form of constipation were reduced to the concept of muscular weakness of the intestinal wall, its atrophy, or loss of tone-atonia of the intestines, then at present the disturbance of intestinal dynamics is considered not so much as a weakening of the normal strength of the muscular layers of the intestine itself, but as a disturbance of the setting of its neuromuscular apparatus. In some cases, this involves a decrease in peristalsis of the large intestine due to weakening of irritation of its nerve apparatus, both as automatic ganglia and as other parts of the autonomic nervous system, while in other cases, on the contrary, the basis of constipation lies in the enhanced work of this same neuromuscular apparatus, as a result of which spastic contractions of the intestine appear on a limited or large area of it. Thus, both hypoperistalsis of the intestine and local increase in the tone of its musculature can ultimately give the same result-functional retention of feces. It is easy to imagine that these two, to some extent opposite, pathophysiological processes, combining with each other in individual cases, cause a disturbance of the entire correct and expedient dynamics of the intestines, giving dyskinesia-48 G of the intestine,-dyskinetic constipation. This is exactly what happens in practice, with either hypoperistalsis or local enhanced contraction of the intestine predominating. 3. Due to the reduction in motor activity of the intestine, constipations are called atonic, while those resulting from convulsive contraction of the intestinal wall are called spastic (Fleiner). Atonic, or more correctly, hypokinetic (Schwarz) constipation arises as a result of the automatic nerve apparatus of the intestine, first of all Auerbach's plexus, either being weakly irritated or partially losing the ability to perceive irritation (Noor-den). In the first case, it may be either a weakening of hormonal influences stimulating the activity of the intestine, for example a decrease in the secretion of choline (Magnus, le Héx), or a decrease in normal food irritation (alimentary constipation), or finally (as Ad. Schmidt thought) about excessive digestion of food by the intestine with the use of its slags (hyperpepsia, obstipatio hyperpeptica). The constitutional increase in the enzyme digesting cellulose, which underlies hyperpepsia as represented by A. Schmidt, is currently considered unproven; here it is probably a matter of the fact that due to abnormally large assimilation of food, little material remains for the usual intestinal microbes of fermentation and putrefaction, as a result of which too few acids are formed that irritate the nerve apparatus of the intestine (Strasburger). The second cause of hypokinetic constipation may be an incorrect setting of the automatic nerve apparatus itself either due to blockade by the sympathetic nervous system or (which happens much more often) due to an increase in the threshold of irritability as a result of frequent and strong irritants (e.g., strong-acting laxatives or enemas). It is very likely that the inherent cyclic automatic activity of the intestine (Lenz) also decreases due to frequent suppression of the usual reflex under conditions of cultural life. This explains the atonic forms of constipation in students who are embarrassed to leave the classroom when the urge appears, in sewing workers, etc. It is very possible that habitual constipations as a result of a sedentary lifestyle (mental workers, officials, etc.) also partially belong to this form of constipation. Hyperkinetic, or spastic constipation was identified as a special form of constipation in 1893 by Fleiner and, despite significant objections from various sides (Boas, Schmidt, Strasburger, etc.), from the very beginning found adherents among clinicians (A)bu, Roseriheim, Singer, Westphalen, etc.). However, here we are dealing not only with prolonged spasms of individual sections of the large intestine (as Fleiner thought), which for a long time delay fecal masses in one place, but with a disturbance of the normal systematic progression of fecal masses through the intestine due to enhanced, disorderly, and therefore inexpedient peristalsis of the large intestine (Singer, Holzknecht), with the appearance of either local spastic contractions of the intestine that push back the fecal cylinder, the so-called 'retrograde transport,' or rapid peristalsis carries insufficiently formed feces to the distal end; in short, as a result of the abnormal irritability of the intestine, there is a significant dissociation of the normal dynamic processes in the intestine (Stier-Ип), the final result of which is the retention of feces. The causes of hyperkinetic constipations are very diverse. In some cases, it is a matter of increased irritability of the intestine due to inflammatory or ulcerative processes, sometimes insignificant in their anatomical substrate, e.g., in fissures of the anus, in others- of reflexes on the parasympathetic system from various organs of the abdominal cavity, especially the urogenital apparatus; finally most often spastic constipation is the result of dystonia of individual parts of the autonomic system with predominance of the tone of the parasympathetic nervous system, both its cranial and sacral parts. To a large extent, this includes the very frequent psychoneurogenic constipations, often on the basis of sexual disorders.- To the dyskinetic constipations can also be included the proctogenic constipation identified in 1906 by Strauss (Strauss), also called dyschezia (dyscheziallertz'a) or torpor of the rectum (torpor recti Singer's). This form of constipation consists in that in the patient due to hypesthesia or anesthesia of the distal segment of the intestine-ampullae recti-there is no urge to defecate, which normally appears as a result of stretching of the rectum by fecal masses or gases (see Defecation). Due to the absence of a signal for defecation, the feces, without any anatomical obstacles for emptying the intestine, stagnates in the rectum for many days. This form of constipation appears as a result of prolonged painful defecations that force the patient to refrain from acting on the urge and suppress it, or due to false shame leading to suppression of the urge to defecate, with abuse of enemas, etc. Although pathogenetically all other forms of functional constipations result from the arising dyskinesia, i.e., have at their basis atonic or spastic constipation or proctostasis, but practically for the sake of prevention and proper treatment it is still expedient to etiologically distinguish them from pure forms of habitual constipation. These include the following forms of constipations. 3. Constipations of endocrine origin. Very little is still known about the origin of the choline-hormone, which stimulates peristalsis of the intestines, or the so-called peristaltic hormone (Peristaltik-hormone), presumably secreted by the spleen, which is why it is difficult to speak at present about constipations that are the direct result of a decrease in the production of these substances. The influence of the endocrine glands on the intestine is not without interest: thus, in hypothyroidism, persistent constipations appear (Payr). In tetany as a result of damage to the parathyroid glands, Peritz considers the appearance of spastic constipation possible. Eppinger and Hess (Eppin-ger, Hess) saw spastic constipations in patients with hyperplasia of the thyroid gland. Persistent constipations were observed in acromegaly and dystrophia adiposo-genitalis. The pharmacodynamic influence of the hormone of the posterior part of the pituitary gland on the tone of the intestine is known-sometimes a single injection of pituitrin eliminates constipation. However, to the present day, endocrine constipations are still very little studied and therefore have little practical significance at present. 4. To toxic constipations belong chronic constipations in professional poisonings (see below), in nicotine poisoning in smokers, in morphinism and finally in abuse of drugs (e.g., opium) or food with a high content of tannins; familiarity with this form of constipation is of great importance for the prevention of these constipations. 5. Reflex constipations, being the result of a visceral-visceral reflex, i.e., a reflex from one or another diseased organ of the abdominal cavity to the intestine, can be either atonic with excitation of the sympathetic nervous system ('sympathetic constipation'), or spastic, if the excitation is transmitted to parasympathetic fibers.

These include numerous cases of constipation, predominantly in diseases of the sexual sphere, both in women (diseases of the uterus and especially its appendages) and in men (posterior urethritis, prostatitis, epididymitis, etc.), as well as in a number of sexual disorders (coitus interruptus, masturbatio); this also includes constipation in diseases such as renal pelvis, especially in kidney stones, in cholecystitis, cholelithiasis, etc. Determining the source of the reflex causing constipation has great practical significance, as it makes it possible to establish correct causal therapy for constipation. 6. Diseases of the central nervous system are often accompanied by persistent constipation not amenable to ordinary therapy. These include constipation in the initial forms of tabes dorsalis, which present great diagnostic interest, as well as in the beginning stages of spinal cord tumors, constipation in myelitis and in inflammations of the meninges, both spinal and cerebral, etc. 7. Psychoneurotic constipation occupies a special and extremely important place among constipation of functional origin. In humans, the very act of defecation is largely subject to the psyche and is developed through the formation of certain conditioned reflexes, which have enormous importance in establishing normal intestinal dynamics. Therefore, disruption of the proper conditioned reflexes often leads to the appearance of delayed bowel movements. This includes, for example, constipation in the first days of train travel and during other changes in the usual way of life. This also includes various forms of constipation resulting from suppression of the habitual urge to defecate, i.e., inhibition of the developed conditioned reflex. But the entire psychoneurotic activity of a person does not remain without influence on the activity of his intestine; this includes persistent constipation in mental workers, constipation in mental depression, nervous exhaustion; in the latter case, more than in a sedentary lifestyle, one should look for the cause of constipation in scientists, writers, lawyers, doctors, responsible political and professional workers and generally in persons whose activity is associated with mental strain; this also includes a number of constipation resulting from mental conflicts lying below the threshold of consciousness, especially on a sexual basis. Constipation can finally become the center of the patient's attention and then become the starting point of major mental experiences, based on incorrect ideas about the harm of constipation due to, for example, auto-intoxication. By fixing their attention on the quality and quantity of bowel movements, the patient creates a new mental conflict, which significantly intensifies the constipation itself due to increased tone of the parasympathetic system and thus enters a vicious circle. This gives the clinical forms of constipation, already known to old physicians as hypochondria intestinalis. Thus, having very different psychophysiological origins and very diverse mechanisms of development, psychoneurotic constipation presents particularly great practical interest, and correct recognition of them gives the physician the opportunity to find the right path to their prevention and therapy, sharply different from those in constipation of other origin. 8. Professional constipation is characteristic mainly of persons engaged in work requiring a sedentary lifestyle and is therefore found in office and clerical workers, in sedentary mental workers, in persons who travel frequently by train. Physical laborers as a rule do not suffer from habitual constipation and, conversely, when switching to office work and sedentary employment, they develop constipation. Constipation due to professional poisoning is found in industries and branches of industry where work is associated with lead: in smelters of lead ores, in workers manufacturing lead boxes, pipes, buckets, wire, retorts, in those casting printing type, preparing and working with lead white and other lead paints, in painting, in the ceramic industry (potters). In factories of aniline dyes, where methyl bromide or methyl iodide is used, professional constipation is also observed in workers due to chronic poisoning by these substances. Thus, chronic constipation, manifesting itself very uniformly in one main symptom of the disease - delay in bowel movements, has a very diverse etiology, ranging from gross anatomical changes in the shape and patency of the intestine to the subtle, barely perceptible play of the psyche, escaping both the physician and the patient. Determination of etiology and pathogenesis constitutes the practical difficulty in recognizing and treating constipation, all the more so that various causes of constipation can give very bizarre combinations and barely noticeable anatomical damage is often accompanied by severe disturbances in intestinal dynamics, while gross organic defects, compensated by neuromuscular apparatuses, sometimes can occur without disturbance of the physiological functions of the intestine. Clinical picture. Despite the great diversity in the pathogenesis and etiology of constipation, its symptoms are very uniform. - Subjective complaints of patients come down to phenomena from the intestine and symptoms from other organs and systems. However, it should be noted that a significant number of people suffering from constipation for a number of years do not turn to a doctor at all, being content with the systematic use of various laxatives or frequent enemas. This alone indicates that constipation itself usually does not give any severe subjective sensations. Some patients complain of the absence of the urge (this is most often observed in proctogenic and atonic forms of constipation), others, on the contrary, complain of frequent but completely fruitless urges to defecate, ending after long efforts with the expulsion of one or two balls of densely compacted feces, with the patient remaining with a feeling of complete dissatisfaction with defecation (fragmented stool of Boas); these are patients with hyperkinetic, or spastic forms of constipation. Sometimes added to this are complaints of pain in the anus from irritation by hard fecal plugs. Often patients complain about the appearance of bowel movements, frightening them with their black color of 'overcooked' feces and the mucus coating them; this arouses in them a series of hypochondriacal ideas. Dyspeptic phenomena from the stomach, bloating of the abdomen are not characteristic of the subjective picture of chronic constipation. Abdominal pains are rare and have a colicky character, without definite localization, depending most often on the retention of gases, which in general are not abundant in these patients, and are more often observed in spastic constipation. Patients with chronic constipation present a whole series of complaints that have no direct relation to the digestive tract. These include: headaches, dull, localized more in the parietal and occipital regions, bad mood, depression, reluctance to mental work, weakening of memory, 'fog in the head', palpitations, bad taste in the mouth, odor from the mouth, etc. All these complaints patients associate with constipation and assure that relief immediately eliminates these phenomena, which actually forces patients to resort to enemas and laxatives. It is very difficult to give a correct explanation for the origin of these phenomena. The doctrine of auto-intoxication of the organism from the intestine (Bouchard) to explain these phenomena (see Intestine) encounters a number of serious objections; firstly, absorption of decomposing feces is possible only when it is in liquid form, secondly, feces in constipation do not show signs of increased decomposition and for example, in a fermentation test does not give products of either putrefaction nor fermentation. An increase in the amount of indican or ether-sulfuric acids is by no means always present in these patients and is little evidence for intestinal auto-intoxication. The most probable must be considered that the general phenomena in patients with constipation occur either reflexively due to irritation of the intestine by hard fecal masses with subsequent influence on the vasomotor and nervous system, or these phenomena represent symptoms of the general neuropathy of the patient, with constipation to be considered only a partial manifestation of functional disorders of the nervous system. In any case, patients suffering from constipation very often present a series of complaints of a psychoneurotic order, and as was seen, in the pathogenesis of a whole series of constipation, the mental state and mood of the patient often play a dominant role. Objective signs of chronic constipation are extremely poorly expressed and often even completely absent. On examination of the abdomen, it is rarely possible to detect bloating: meteorism does not belong to the symptoms of constipation. Palpation of the abdomen sometimes reveals individual sections of the intestines filled with dense fecal masses, most often in the area of colon descendens and flexura sigmoidea, more rarely in colon ascendens and in caecum. In hyperkinetic constipation, it is sometimes possible to feel a spastically constricted section of the intestine in the form of a strand, as thick as a finger, somewhat painful on palpation. Much greater results are obtained from the examination of the rectum per anum.

The inserted finger reveals either huge accumulations of fecal masses—in proctogenous constipation, or a sluggish intestine that does not respond to palpation—in atonic constipation, or finally a sharp contraction of the intestine that grips the finger so tightly that it can with difficulty be extracted—in severe spastic constipations; thus, palpation of the rectum has some significance for determining the nature of constipation. Even greater significance is attached to the macroscopic examination of the feces. The amount of water in the feces in constipation is less than normal and reaches 60% (instead of the normal 80% content in feces); the feces are dry and usually do not have a particularly foul odor. The external appearance of the feces varies in different forms of constipation. In proctogenous constipation, large amounts of formed feces are discharged; in atonic constipation, the feces are dark-colored, cylindrical in shape with longitudinal imprints of taeniae or in the form of clumps—scybala, now larger, now smaller. In spastic forms, the feces have a flattened shape, sometimes in the form of a ribbon, or are discharged in small, faceted clumps like sheep's feces. For some spastic constipations, the appearance of mucus in the form of a thin web enveloping the fecal clumps is characteristic. This mucus can be secreted without a catarrhal process as a result of the reaction of the intestinal wall to mechanical irritation by feces. Sometimes on the surface of the feces, individual blood streaks can be seen as a result of mechanical damage to hemorrhoidal nodes or the mucous membrane of the anus itself by hard pieces of feces. Chemical and microscopic examination of the feces usually gives nothing characteristic for constipation and is superfluous, in contrast to this examination in diarrhea, where it has particularly great diagnostic significance. In some cases, proctoscopy can clarify the situation in more detail; thus, by this method it is easy to establish the cause of constipation in megacolon congenitum, to easily see the sharp spastic contractions of the intestine in hyperkinetic constipation, to easily detect slightly ulcerated hemorrhoidal nodes above the sphincter ani externus causing spasm, etc. X-ray examination of the intestine, by administering contrast food followed by repeated observation of its passage through the large intestines, can significantly supplement our knowledge both about the localization of constipation and sometimes about its form. In a series of cases, it can be seen that the contrast mass remains for a long time, for example for 24-36 hours, in the colon ascendens and caecum and only partially in the form of individual clumps from time to time appears in the distal parts of the large intestines. This type was isolated by Stierlin as a special form of ascending constipation, dependent on the spasm of the so-called Keith's sphincter (Keith), a physiological sphincter located between the first and middle third of the large intestine; this form corresponds to the so-called 'right' constipation of French authors (stase colique droite, la constipation droite); according to Thaysen, this form occurs in approximately 18% of all cases of chronic constipation. In contrast to this form, another form is radiologically distinguished, where the contrast mass accumulates in the colon descendens (la constipation colique gauche of French authors) and finally a third, proctogenous form, in which the contrast masses remain for whole days in the flexura sigmoidea and in the ampulla recti; according to Thaysen, these are the most frequent forms of constipation and occur in 60% of all cases. In addition to localization, X-ray examination makes it possible to differentiate atonic constipations, when contrast masses lie for hours, for example, in the colon transversum in the form of a wide, lifeless ribbon, and hyperkinetic forms, where the spastically contracted intestine divides the entire contrast mass into a series of clumps far distant from each other. It should be noted, however, that it is precisely the X-ray examination that established the frequency of mixed forms of constipation both in terms of localization and the very nature of constipation. At the same time, there is an opinion that the X-ray picture of the intestine reflects not so much the pathophysiological processes of intestinal dynamics as the constitutional setting of the intestine in different types of people, which to some extent reduces the diagnostic value of X-ray examination in constipation (Holzknecht).-Among phenomena from other parts of the digestive tract, the frequency of hyperchlorhydria of gastric contents is noted (Noorden), which in spastic constipation finds its explanation in the increased tone of the entire parasympathetic part of the autonomic nervous system. From the side of the heart, sometimes disturbances of rhythm—extrasystoles, bradycardia, and sometimes, conversely, tachycardia—can be observed. The accompanying phenomena from the skin in constipation are of considerable interest. Often urticaria and a series of dermatoses in the form of eczema, furunculosis, disappearing when constipation is eliminated (Noorden, Salomon) can be observed, whereby a genetic connection, perhaps of an allergic type, between the processes in the intestine and these diseases is not excluded. Although, especially by older authors, cases of epilepsy, migraine, neuralgia, and psychoses that were cured after eliminating constipation were described, still the direct connection of these diseases with constipation should be considered very problematic. Among the body's reactions to constipation, older authors noted feverish increases in temperature; however, if we are not talking about symptomatic constipation, where an increase in temperature may be associated with the underlying disease, functional constipations do not give fever, and the patients' complaints of chills and fever find their explanation in the reflex play of vasomotors. Diagnosis. The fact of habitual constipation is most often established already from the history and complaints of the patients. It is much more difficult in each individual case to recognize the form of constipation. Differential diagnosis between symptomatic constipations in organic diseases of the intestine and purely functional constipations is particularly important. In this respect, one should be careful when constipation appears in more mature age, after 40 years, especially in persons who previously had a normal stool or a tendency to diarrhea; the point is that an apparently innocent constipation, attributed to a sedentary lifestyle or change in diet, is sometimes an early symptom of beginning narrowing of the intestine by a tumor. Here, systematic X-ray examination, and sometimes proctoscopy and even simple examination of the rectum with a finger (strictures of the rectum) are of great importance for clarifying the true state of affairs. It is much more difficult to recognize functional constipations from inflammatory ones in colitis (see). The recognition of functional constipation cannot yet be considered the end of the question; it is urgently necessary to establish whether there is hypo- or hyperkinetic constipation or proctostasis; and mainly—what etiological factor lies at the basis of this form of constipation, because it is precisely such precise individualization of the diagnosis that is an indispensable prerequisite for correct and successful treatment of constipation. The peculiarities of each form of constipation, outlined above, form the basis for differentiating constipations. Prevention of constipation represents the most important and most grateful task for the physician. Here it is necessary to emphasize the need to carry out a series of preventive measures of a large public nature, connected with the reform of the population's way of life and its habits. It is necessary to organize, for example, extensive sanitary-educational work in the fight against an exclusively meat diet with a very small amount of vegetables and fruits, which has taken root among the majority of the urban population; it is necessary when organizing collective feeding in public canteens, in hospitals and especially in sanatoriums, rest homes, children's homes, to pay attention to the composition of the food, individualizing it for persons constitutionally predisposed to constipation, and prescribing for them food with a large amount of roughage. It is necessary to pay attention to iatrogenic constipations resulting from the stereotyped prescription of the so-called 'strict' diet and to give patients more precise instructions about their nutrition for a certain period, taking into account the possibility of alimentary constipation. It is necessary to limit the uncontrolled use of drugs (opium, astringents). It is necessary to regulate sedentary occupations of mental workers, insisting on the carrying out of reasonable physical education, to be concerned with normal load, especially for persons constitutionally predisposed to dystonia of the autonomic nervous system. It is necessary to fight excessive smoking. Finally, in constipation as an occupational disease (in industries where there is a danger of lead poisoning and in the production of aniline dyes), it is necessary to take timely preventive measures to detect patients in the early stages of the disease. Thus, prevention of constipation is closely connected with a series of measures aimed at regulating labor and improving the population's way of life, i.e., with the tasks of the country's cultural revolution, and should become the subject of constant care and systematic sanitary education of the population. Treatment of constipation can be a) dietary, b) physiotherapeutic, c) medicinal, d) psychotherapeutic, e) balneological, f) surgical, but must always have as its prerequisite correct individual recognition of the form of constipation, dictating in practice the line of conduct of the physician in each individual case of constipation.

Dietary therapy for alimentary and hypokinetic forms of constipation aims to enhance the insufficient stimulation of the intestine by prescribing food that provides a large amount of slag or chemically irritates the intestinal wall, and to remove from the diet substances that are especially easily and well digested by the stomach and intestine. Therefore, in these forms of constipation, the consumption of meat and fish soups, lean varieties of meat, fish, white bread, cookies made from fine grades of flour, cocoa, rice, semolina, potato porridge, etc. is limited, and food substances with a high content of cellulose and hemicellulose are prescribed. These include black bread, sifted bread, honey gingerbread, buckwheat porridge, vegetable and fruit soups, cabbage, cucumbers, beets, salads, carrots, turnips, radishes, peas, beans, mushrooms, apples and other fruits, especially plums. Vegetables and fruits are served as much as possible in a raw and finely ground form. Among food substances that irritate the intestine with their chemical composition belong sugar, especially fruit and milk, honey, sour milk. From beverages, carbonated cold waters are recommended. This diet should be carried out very gradually and is considered a rough anti-constipation diet. - The diet for spastic forms of constipation is composed completely differently. Here, the prescription of coarse substances that irritate an already irritated intestinal wall is inappropriate. Therefore, for such patients, plant food containing cellulose is recommended only in a pureed form, with special importance attached to the prescription of fats, cream, butter, and olive oil, which reduce intestinal spasm. Vegetables and fruits are prescribed in a cooked form with a significant addition of sugar. For spastic constipation, a paradoxically anti-constipation diet (Rosenfeld) that calms the irritated intestine is even proposed. Therefore, cold beverages, especially carbonated ones, are prohibited, and tea and coffee with cream are preferred. Such a diet is called a gentle anti-constipation diet. Physiotherapeutic treatment of constipation is also completely different for hypo- and hypertonic forms. For atonic constipation, medical gymnastics with exercise of the abdominal press, cold or Scottish shower, cold rubbings and douches of the abdomen are indicated; opinions on the benefit of abdominal massage for constipation differ considerably, and many see in it only a method of psychotherapeutic influence on the patient. However, for proctogenic constipation, massage of the rectum and the application of faradic current with an anal electrode are appropriate. This also includes the treatment of constipation by sports (mountain climbing, rowing, swimming, horseback riding, Zander gymnastics). For spastic constipation, all the above procedures are contraindicated. Here, bed rest, hot water bottles, warming alcoholic compresses, warm aromatic sitz baths, diathermy are appropriate. All kinds of massage and gymnastics are completely excluded. Medicinal treatment of constipation, extremely widespread among the population, in essence has the value of a palliative that very often leads only to a worsening of the disease. It is fundamentally necessary in the treatment of constipation to limit as much as possible the use of laxatives, as a rule prescribing only the mildest ones, predominantly of plant origin; these include preparations of rhubarb, Pulv. Liquiritiae coct.; sometimes Cascara sagrada or Regulin, containing agar-agar with Cascara sagrada, and others. Podophyllin, aloe, jalap, castor oil and strong mineral laxatives (Natrium sulfuricum, Magnes. sulfuric) are completely contraindicated in chronic constipation; it is hardly advisable to recommend for long-term use most patented preparations containing often strong laxatives, e.g., phenolphthalein. The same applies to systematic washing, enemas, especially if they contain substances irritating to the intestine, e.g., soap. Both laxatives and enemas, used daily in increasing amounts, always lead to a decrease in the irritability of the neuromuscular apparatus of the intestines, and consequently, to a worsening of the underlying disease despite temporary symptomatic success. This applies to atonic and proctogenic constipation, especially to its spastic forms, where irritation of an already very sensitive intestine leads to an intensification of the spasm accompanied by significant pain, with subsequent exacerbation of the disease. In these cases, great service is rendered not by laxatives, but by antispasmodic agents, and in the first place by atropine, recommended by Trousseau for the treatment of constipation. The systematic prescription of Atropini sulfurici in a dose of 0.001-0.01 mg 2-3 times a day often brings great benefit to patients; instead of atropine, Extractum belladonnae no 0.015-0.02 can also be prescribed internally and in suppositories, and among the newest preparations, Eumydrin and Bellafolin. The prescription of warm (31-32°C) oil enemas of olive oil, sunflower oil, as well as enemas of Paraffinum liquidum is also of great importance for spastic constipation. However, their action should not be considered as evacuating, but as antispastic, for which reason the enemas should be administered at night and retained until morning, preferably 2-3 times a week, 1-2 glasses of pure oil (without water), introduced slowly into the intestine with a soft, long nozzle. Organotherapeutic treatment of constipation is very tempting but little studied. This includes the prescription of Neo-hormonal'fl no 15-20 cm³ intravenously as proposed by Zülzer; excellent results from it were observed in individual forms of atonic constipation, with a single infusion for a long time stopping habitual constipation. The prescription of Pituitrin is also recommended. In cases of constipation based on hypothyroidism, excellent results are obtained from the prescription of thyroid preparations. Psychotherapeutic treatment of chronic constipation plays a major role due to the significant involvement of the psycho-nervous factor in the pathogenesis of a number of constipations. In only rare cases is hypnotic suggestion or the application of psychoanalysis necessary. Often, the ordinary psychotherapeutic suggestion of the doctor is quite sufficient to obtain a good result. It is necessary to carefully study the patient's history to determine, where possible, the influence of mental irritations and conflicts on intestinal activity in individual cases and to fight against the patient's incorrect ideas about the harm of constipation and the benefit of laxatives, while at the same time, as much as possible, eliminating psychogenic causes of constipation. No less important is the cultivation of lost conditioned reflexes, i.e. 1) prohibition of disorderly visits to the toilet at different hours, 2) distraction of the patient's attention from the act of defecation, 3) specific advice for establishing new conditioned reflexes and releasing the inhibiting influences of the psyche, etc. In all forms of constipation, especially in hyperkinetic ones, the psychotherapeutic influence of the doctor has enormous importance both as a preventive measure and as a purely therapeutic means. Balneological treatment of constipation, although indicated, should not be attributed entirely to the influence of drinking the water of the source itself. The constant use of bitter waters (Batalinsk source) is contraindicated. As a drink, Essentuki waters, cold iron-containing waters from Zheleznovodsk are used. Resort treatment has significance not so much from the use of drinking waters as from the general influence of a change of environment on the psycho-nervous activity of the patient: unloading him from habitual irritations, change of impressions, diet, way of life. Thus, in resort treatment, one can see a powerful psychotherapeutic method of treatment, successfully combined with the possibility of applying a dietary regimen, physical culture, and physiotherapeutic treatment. This is the only explanation for the temporary beneficial effect of the resort on constipation and the necessity of applying preventive measures when the patient returns to the usual conditions of work and daily life.

r. Luria. Surgical treatment. It is most difficult to treat constipation caused by organic causes, which include congenital abnormalities in the position of the large intestine, abnormal mobility of individual parts (caecum mobile), Hirschsprung's disease and related conditions (megacolon, megacaecum), various constrictions and bends, partly caused by remnants of inflammatory processes and consequences of dysentery, incarcerations, and partly being the result of adhesions of congenital (Jackson's membranes, Lenn's bands) or inflammatory nature. Constipation of the same nature includes cases of insufficiency of the Bauhinian valve, described by Rozanov, and finally enteroptosis. But even severe forms of functional constipation sometimes become objects of surgical intervention. - To eliminate constipation depending on the mobile cecum, the simplest of operations is applied: fixation of it with several sutures and suturing of the wall when it is expanded. In case of insufficiency of the Bauhinian valve, Kellogg and Rozanov incise the plica ileo-caecalis, which corrects the acute angle of the entry of the small intestine into the cecum (a symptom, according to Rozanov, typical for insufficiency of the Bauhinian valve), after which the small intestine is fixed with several sutures to the ascending colon. According to Rozanov, this operation leads to the descent of the upper lip of the large valve and to the creation of 'a new artificial semilunar fold (plica semilunaris)'. In all (11) cases of Rozanov, complete healing from constipation occurred. Too small a number of such observations still does not allow making any conclusions one way or another. - For the treatment of Hirschsprung's disease and similar conditions, resection is more often used at present. The disputes are mainly about the one-stage or two-stage nature of the operation and about the size of the resected segment (see Hirschsprung's disease). In constipation depending on compression or bending of the intestine by bands and adhesions of congenital origin, their incision cures the patient. Bands and adhesions formed as a result of inflammatory processes of the abdominal cavity (see Peritonitis), often after their incision, quickly form again, and everything returns to the previous state. Here, physiotherapeutic procedures (iontophoresis, mud baths, etc.) give greater success. 49S The question of surgical treatment of constipation due to ptosis of the intestine, which is usually only one of the manifestations of general ptosis, has undergone great changes. Fixation of the intestine is now abandoned by all surgeons and does not lead to the goal, since after a greater or lesser period of time everything returns to the previous state. Franke in 1902 proposed for functional constipation and constipation due to ptosis to apply a series of enteric-enteroanastomoses. The proposal found many followers, but further observations of patients and experimental animals showed that despite the applied anastomoses, the movement of intestinal contents went in its usual way. In the segments of the intestine, excluded due to the anastomosis, accumulation of fecal masses occurred with all its consequences, the condition of patients after the operation sharply worsened, which sometimes forced the surgeon to decide on a re-operation either to remove the applied anastomoses or to resect the large intestine. The question raised by Mechnikov about the harm of the large intestine to the human body prompted Lenn and others to resect the large intestine in intractable constipations, mainly of functional origin. This heavy operation gave in the hands of some authors a significant percentage of healing. Schlesinger at the congress of English surgeons (1922) reported 72% of complete and prolonged healing; Flint from the Moynihan clinic had 50% recoveries out of 68 operations with two fatal outcomes; Herzen had 3 cases with recovery. However, Hurst and Gray reported 16% mortality and 70% unsuccessful (in terms of eliminating constipation) operations. Apparently, this heavy operation should be resorted to only in very severe cases after the unsuccessful application of the entire rich arsenal of therapeutic means. On the treatment of constipation depending on new formations of the intestine, see Intestine.

N. Blumental. Constipation in children. Newborn children have bowel movements several times a day, while infants have 1 to 3 times. The stool in infants is yellowish-golden in color, without any odor, of the consistency of thick paste; artificially fed infants have a bowel movement once a day, lighter if milk predominates in feeding, and darker if flour dishes, cereals, berries, vegetables or meat are added to the food. If the stool is delayed for 1-2 days or more, one usually speaks of constipation; one should consider constipation not only the absence of daily stool, but also insufficient emptying of the intestines. If such a delay in stool is not noticed in time, persistent constipation with all their unpleasant consequences may develop over time. Constipation can manifest from the first days of life if the mother does not have enough milk. In such cases, so-called meconial constipation (constipation meconiale of the French) are observed. Constipation can be the result of mechanical causes that impede the free passage of fecal masses. These causes include narrowings of the intestinal tract. Constipation is often caused by anatomical peculiarities of the intestine, as for example in Hirschsprung's disease, or in flexures in the ileocecal area, or in elongation of the colon. Functional constipation in infants can depend on insufficient amount of milk in the nursing mother, on the composition of the milk, the number of feedings, and the quality and quantity of supplementary food. The regimen of the nursing mother also has an influence on proper emptying. Large errors in her diet, such as consumption of excessive amounts of meat, large amounts of sweets and spices, undoubtedly affect the character of the child's stool. In all febrile diseases, a decrease in appetite is observed in children, due to which children take less food; the result of this is so-called apparent constipation (Scheinobstipation), which pass by themselves after the temperature drops. In nervous children, constipation often develop on the basis of refusal of food; the use of force in feeding such children further increases aversion to it and often brings them to a state where the mere sight of food already causes vomiting. In these cases, the amount of food taken is insufficient to stimulate intestinal peristalsis, as a result of which constipation develops. After weaning from the breast, constipation develop in children who continue to receive exclusively milk, or in those for whom milk is the main and predominant basis of nutrition. Among constitutional diseases, which are in most cases accompanied by constipation, rickets and neuroarthritis should be noted. Many infectious diseases are also often accompanied by constipation; these include influenza, typhoid fever, rheumatism. Constipation are observed as a rule in tuberculous meningitis in children over 3 years of age. Constipation are often reflexive in diseases of individual organs, such as: in bladder stones, in appendicitis. Delay in stool is particularly often noted in fissures of the anus. The pains caused to the child each time during the passage of feces make him delay the stool and ultimately develop psychological constipation in him. Spastic constipation are less common in childhood, but still with general neuropathy, along with other phenomena of spasmophilic character, the spastic form of constipation must be kept in mind. In functional constipation, no pathological-anatomical changes are found in the intestine. In organic constipation, a change in the lumen, an increase in the flexures of the large intestines, a narrowing of certain sections of the intestine, and a thickening of the walls are found. Prolonged stay of fecal masses in the intestine can cause irritation of the mucous membrane, erosions, and even ulcers. Due to constant stretching of the rectal wall and strong stretching of the sphincters, constipation are easily complicated by prolapse of the recti. In habitual constipation, children usually suffer little. Cherny asserts that children with increased sensitivity (sensible Kinder) very often suffer from constipation, developing due to excessive attention paid by parents to the child's stool. By carefully following the daily action of the stomach, when it does not occur at a certain time, they resort to laxatives or enemas and thus accustom the child to conditioned reflexes. Neurotic children quickly get used to the idea that they cannot have a bowel movement without an enema. In such cases, it is enough for the enema to touch the anus for defecation to begin on its own. This observation proves that such constipation should be treated not by medical measures, but purely by pedagogical measures of influence. Persistent and chronic constipation can be accompanied, in addition to local phenomena, by symptoms of the general reaction of the organism. The act of defecation in them is accompanied by severe pains. Sometimes one still has to achieve a bowel movement by lavage, suppositories or laxatives. The stool in constipation is usually dry, grayish-white in color, is excreted either in cylindrical masses or in the form of goat stool, consisting of fused balls of very dense consistency. The stool is sometimes so compact and dry that, falling into the bottom of the vessel, it gives the impression of falling stones. If the stool has a cylindrical shape, it is often covered with mucus, and in some places with blood. Blood may appear either from inflammatory processes of the rectal mucous membrane or from fissures of the anus, which are almost constant companions of constipation. On examination of the abdomen, great sensitivity is often found; sometimes large accumulations of fecal masses can be palpated, which simulate tumors. Prolonged constipation are sometimes tolerated by some children easily, without any general phenomena, in others phenomena of auto-intoxication are observed, either in milder or in more severe forms. Mild forms can be accompanied by skin rashes, such as urticarial, pruriginous rashes, various forms of erythema and even eczemas. In severe cases, more or less intense headaches are observed, localized in the frontal or occipital part. These headaches are more often during the day; if attacks of headaches occur at night, they are usually accompanied by insomnia, night terrors or severe nightmares. Children suffering from constipation drink a lot and often sweat at night. In such children, arrhythmias and even increases in temperature are often observed. They are pale, anemic, often lose weight and in general appearance resemble initial forms of atrophy. In children suffering from constipation, diarrhea may suddenly appear, which should be interpreted as a consequence of impending toxic poisoning. Constipation in older children are sometimes very pronounced, and the delay in stool can last for weeks. Gevaert observed a 7-year-old child who had no stool for 45 days. The prognosis in constipation is more favorable than in diarrhea. In general, children tolerate functional constipation relatively easily. Organic constipation give a less favorable prognosis, which entirely depends on the underlying cause causing them, such as: congenital malformation, narrowing of the intestines, mechanical compression of the lumen by tumors, etc. Neglected constipation require much more time for their elimination than recently existing constipation. The treatment of functional constipation in children consists mainly of hygienic-dietetic measures. In the first months of life, constipation are often the result of insufficient amount of milk in the mother. Such constipation are easily eliminated by timely prescription of supplementary feeding. Exclusive breast-feeding, if it continues longer than 6 months, also leads to constipation. Constipation are even more often observed in mixed feeding, when the child's food consists almost exclusively of milk (Milchnahrschaden of Cherny) and milk cereals; in these cases it is sufficient to change the diet. First of all, the amount of milk should be limited; in addition, replacing milk with kefir or soured milk is very advisable; it is necessary to introduce flour decoctions, potato puree, puree from other vegetables, vegetable soups, vegetable, berry or fruit juices, compotes, cereals, puree from raw fruits; in the second year of life, berries and washed fruits can be given raw with sugar or syrup. In very persistent cases, Cherny recommends giving nuts or almonds in various dishes. In mechanical constipation, changing the diet gives no results. Here, if the mechanical obstacle is not removable, it is necessary to empty the intestine daily with suppositories, enemas, while one should avoid very large enemas in order not to stretch the intestine. Laxatives should not be systematically used in the first year of life. In older children, constipation in most cases also result from too monotonous food, and therefore the dietary regimen plays an important role here. Such children should be accustomed to coarser food. They can receive general soups, buckwheat porridge, sauerkraut, cucumbers, radishes. They should also be fed with fruits, fruit juices, berries and vegetables. A special service is rendered in such cases by replacing wheat bread with rye bread, or so-called doctor's bread; children eat it more willingly. Staying in the fresh air, air baths, moderate physical exercises and reasonable use of hydrotherapeutic measures often give excellent results in all ages.

In persistent cases, a skilled abdominal massage sometimes produces an effect, which should be entrusted only to an experienced masseur. If constipation is accompanied by persistent headaches, nausea, elevated temperature, and a sharp decrease in appetite, it is better to use oil enemas (Arkavin). For high enemas, a catheter or gas tube is adapted to a rubber balloon of a specific size. The catheter is inserted to a depth such that it passes beyond the S-Romanum; the length of the inserted part of the tube should equal the distance between the thumb and middle finger of the outstretched hand of each patient. For children under 1 year, no more than 30 g is usually administered; in preschool age, 50 g is administered, and for older children, 75-120 g. Usually, provence, sunflower, or sesame oil is used, which is previously boiled for an hour over a slow flame. The technique for administering enemas is as follows: the child is placed on the left side and the specified amount of oil, heated to body temperature, is slowly inserted as described above. The child remains on the left side for 15 minutes, then is placed on the back for 15 minutes, with a pillow under the legs. After 15 minutes, the child is turned onto the right side, on which he falls asleep. Having remained in the intestine all night, the oil manages to soften the fecal masses, and the following morning a counter-flow water enema washes out the softened feces. Water alone, without preliminary oil enemas, has no effect. Such enemas are used until fresh, light-colored feces without any odor are produced. At the same time, the child is transferred to a vegetarian diet with abundant fruits, berries, juices, and vegetables. Milk is excluded from the diet and replaced with kefir, soured milk. During this time, the child must be trained to have bowel movements at specific hours. Kleinschmidt recommends using glycerin suppositories for 8 days in cases of constipation; when independent bowel action is achieved, he replaces them with suppositories from Butyr. Cacao without irritating additives. These suppositories are intended for psychological effect and train the child to proper bowel movements without irritation. At present, oil enemas for constipation have found very wide application in practice both in our country and abroad. Among the medicinal substances recommended for constipation, Sir. Mannae and Sir. Rhei should be noted—1-2 teaspoons daily; Pulvis Magnesiae cum Rheo—to be taken daily on the tip of a knife; Califig—one teaspoon per dose for infants. For older children, the dose should be correspondingly increased. Regulin has proven particularly good for long-term use, which is given with porridge or other food on an empty stomach. Its advantage lies in the fact that it does not change the taste of food and is therefore readily accepted by children. In addition to drug treatment, water treatment can be recommended, for example, Essentuki № 4 or № 17, Slavyanovskaya water in Zheleznovodsk. It is much more useful to use the waters at the resort itself. They have a particularly good effect in cases of constipation that have developed on the basis of a past colitis or dysentery.

y. Arkavin.