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    Constipation is infrequent or incomplete evacuation of the colon resulting in fecal retention.

 ETIOLOGY OF CONSTIPATION.

    The etiology of constipation is obscure.  One writer alone offers some score of causes.  Sluggishness of the bowel, whatever that means, is the most frequently mentioned.  The tractus intestinalis is practically under the domain of the sympathetic nerve, nervus vasomotorius.  Certain general etiologic conditions may be considered:
    I.  Physiology of the tractus intestinalis.  In the etiology of constipation four physiologic factors are involved, viz., (a) peristalsis, (b) absorption, (c) secretion, (d) sensation.  Any one or all of these functions may be impaired.
    II.  Local Causes. - The local causes of constipation may be: (1) splanchnoptosia - inefficient muscular contraction; (2) constriction of some segment of the colon; (3) collections of scybola or intestinal concretions, as in cecum, sigmoid and rectum; (4) enfeebled contraction of the intestinal muscularis; (5) local disease, as appendicitis, cholecystitis, pelvic peritonitis mesosigmoiditis - producing paresis.
    III.  General Causes. - The general causes of constipation are: (1) inefficient function (peristalsis, absorption, secretion, sensation); (2) excessive mental or physical activity) (3) special habits; (4) dietetic errors; (5) diseases of adjacent viscera; (6) factors which induce dryness of feces from inefficient secretion or excessive absorption; (7) impaired peristalsis of the colon.
    IV. Anatomy. - The proper function of the tractus intestinalis depends on a normal nerve, blood and lymph apparatus.  For perfect physiology, a maximum nerve, blood and lymph supply is required.  The muscularis intestinalis, as well as the mucosa intestinalis, must be perfect.  From frequent diseases (catarrh) of pueritas and consequent defective digestion, with resulting deficient nourishment, a non-developed and defective tractus intestinalis remains for life.
    Atrophic or infantile segments of the digestive tract (especially the enteron or smallintestine, which is the essential segment - receiving the secretions from liver and pancreas) burden the adult.  For example, I found in the personal measurements of the enteron in six hundred and five adults that the length of the enteron was, maximum, thirty-two feet; minimum, ten and one-half feet, and average, twenty-one feet.  The enteron (a single segment and the most essential one), the business portion of the digestive tract, varies more than three times its minimum length.  These facts demonstrate that the tractus intestinalis is frequently defective in length, in development, nerve, blood and lymph-in anatomy.  Abnormally diminutive digestive apparatus may occur.  The following recorded data secured by the personal examination of six hundred and five adults, may be suggestive in regard to the anatomy of the tractus intestinalis:

    1.  The average length of the enteron in four hundred and fifty-three males was twenty-three feet.
    2.  The average length of the enteron in one hundred and fifty-two females was nineteen feet.
    3.  Man's enteron averages four feet longer than that of woman.
    4.  The enteron increases in length most rapidly a few months subsequent to birth, when it may grow one and one-half feet a month.
    5.  The enteron assumes its chief length in early childhood.
    6.  The chief variation in the length of the enteron depends on enteritis, compromising the enteronic peristalsis, absorption, secretion, and sensation, and consequently digestion, during early extrauterine life.
    7.  Extraordinary lengths of the enteron depend on the favorable conditions of a maximum enteronic nerve and vascular supply, with maximum assimilation continued beyond the usual period of enteronic development.
    8.  A subject with maximum length of enteron possesses a stronger constitution than a subject with minimum length, as he can digest and economize more food.
    9.  A maximum enteronic, nerve, vascular, glandular, and muscular apparatus, with similar food, would practically produce a similar length of enteron.
    10.  The foods which produce the most vigorous enteronic functions (peristalsis, absorption, sensation, and secretion) are those that leave the greatest indigestible fecal residue, which excites the enteronic muscularis into peristalsis, thus attracting more blood and inciting the enteronic mucosa to, greater secretion and absorption - increasing digestion and, consequently, enteronic growth.
    11.  General and local disease influence the length of the enteron, especially during childhood, the period in life of rapid enteronic growth.
    12.  A child nourished with food which requires vigorous digestion, leaves a fecal indigestible residue, as cereals, would attract more blood to the enteron, enhancing its growth, than one nourished on milk only, which passes through the enteron without inducing vigorous peristalsis, and leaves little indigestible residue.
    13.  The human enteron presents colossal differences as to length: Males 11 1/2 feet minimum, 32 feet maximum = 20 feet; female 10 1/2 feet minimum feet, 30 feet maximum = 19 1/2 feet.  This variation of twenty feet is almost equal to the length of an average enteron.  The enteron varies over double, or two and one-half times its length.
    14.  In adults the relation of the length of the enteron to the body length is as 7.2 is to 1.  There is a vast difference between the absolute and relative length of the enteron of man.
    15.  The enteron measured in situ is three to six feet less in length than when extirpated.
    16.  Different diseases of the enteron may result in elongation or contraction.  The above defects are not heredity, but acquired by disease.  They will offer a clew to conditions for constipations.

    V.  Mechanical. - Constipation may arise from stricture, flexions, peritoneal adhesions, neoplasm, splanchnoptosia, obstruction of lumen.
    VI.  Dietetic. - Quality of foods, quantity of fluid, chemical composition, are important considerations. (a) Food must possess sufficient variety (mixed) in quantity, quality, chemical composition, and be ingested at regular intervals.  The food should be mixed, however, and possess sufficient indigestible matter to leave ample residue to stimulate peristalsis (and hence absorption, sensation, and secretion).  An excessive amount of coarse, indigestible food will result in an excessive fecal residue, which excessively stimulates peristalsis, absorption, secretion and sensation-resulting in muscular fatigue and defective sensibility of the mucosa-consequently reflex action is impaired. (b) Ample fluids at regular intervals should be ingested.  For a person of one hundred and fifty pounds three pints daily is required to supply the bodily waste (i. e., for tractus intestinalis respiratorius, urinarius, perspiratorius); eight ounces should be drunk every two hours for six times daily.
    Fecal matter is about seventy-five per cent fluid and twenty-five per cent solid.  The value of fluids for the tractus intestinalis is evident, because in hot weather, with consequent vigorous activity of the tractus respiratorius, constipation results.  The chief value of mineral water is the quantity drunk.  Excessive fluids deteriorate digestion; (c) foods should possess chemical qualities.  Carbohydrates produce acidity, nitrogenous foods alkalinity, and mixed foods neutrality of the digestive tract.  Evacuation of the tractus intestinalis depends on (a) sufficient volume of feces, (b) sufficient volume of fluid contents, (c) the presence of substances which act as a chemical irritant to peristalsis.  Dr. Walter Baumgarten attempted to devise a substance which would not only be difficult to absorb, but would retain its watery contents.  He adminstered eight grains of the dry, shredded agar-agar three times daily, whence he found the stool increased in volume and watery content.
    VII. Pathologic. - The pathologic impairment of peristalsis, secretion, absorption, and sensation of the tractus intestinalis, must be studied to account for the constipation.
    Chronic peritonitis, an important factor in constipation, is frequently due to chronic peritoneal inflammation.  In the major regions of peritonitis the story of constipation is told.  Chronic peritonitis occurs in the oviducts (80 per cent), in the ileo-coeco-appendicular region (70 per cent, over right psoas), in the mesosigmoid (80 per cent, over left psoas), in the cholecyst and right colonic flexure region (45 per cent), between the right kidney and the liver (40 per cent), i. e., muscular trauma on viscera induces the migration of germs or their products through the visceral mucosa, muscularis and finally into the adjacent peritoneum inciting plastic peritonitis.
    There may be defective innervation of the muscularis of the digestive tract and abdominal wall (splanchnoptosia).  Brain and spinal cord disease (insane and neurotic) and exhausted disease.
Inhibition of reflex action may arise to check defecation, as from fissure, ulcer, hemorrhoid, operation, painful vesical affections, hypertrophy of anal sphincter.  Also constipation is associated with lethargy or sluggishness of the bowels from local peritoneal or visceral inflammation, as appendicitis, ovaritis, salpingitis, cholecystitis, pelvic peritonitis.  It is in such cases that opium (a sedative to the local irritation) acts as a cathartic.
    The state of the contents of the bowels is significant as chronic dyspepsia, irregular eating and evacuation and insufficient fluid accompanying the food.
    Anatomic peculiarities may lead to constipation, as elongated cecum, sigmoid, and adherent     U-shaped transverse colon, all of which may lie in the pelvis.  Much of constipation is a perversion of the sympathetic nerves controlling the tractus intestinalis.
    VIII.  Sex. - Woman is more liable to constipation than man, because in her the tractus genitalis is violently changed periodically - robbing the tractus intestinalis of its usual quantity of blood (puberty, menstruation, pregnancy, and pelvic disease); (2) woman is less active, more sedentary than man; (3) woman is afflicted with more splanchnoptosia; (4) woman experiences more changes in her visceral circulation (during sexual life) than man (physiology and pathology of genitals).
    IX.  Age Relations. - In senescence constipation may occur from limited food employed, limited exercise, and limited functions, due to the degeneration of senescence.  In senility, peristalsis, absorption, secretion and sensation is limited from limited blood supply, due to arterio-sclerosis.  In peuritis anatomic peculiarities exist.  The tractus intestinalis develop irregularly, the nervous system is not in final established control, the mucosa, muscularis, tractus nervosus and tractus vascularis may be defective in development.  Catarrh occurs with facility and frequently.  The tractus intestinalis is subject to vast vicissitudes of fortune, both in regard to food and attacks of catarrh.  Hence its circulatory life - its basic life - is subject to vast, frequent and rapid changes.
    Constipation is a neurosis of the fecal reservoir.  It belongs essentially among the affections of the sympathetic nerves.
    The system of nerves (including Auerbach's and the Billroth-Meissner plexuses) which rule the gastrointestinal tract is strictly in the domain of the sympathetic.  However, the physiological manifestations of the nerves ruling the enteron are quite different from those ruling the colon.  The nerves ruling the enteron act with intense vigor and great rapidity.  The nerves ruling the colon and rectum act with moderate force and very slowly.  The enteron rapidly forces the contents of Bauhin's valve in a few hours.  The nerves of the colon and rectum act slowly, evacuating the fecal reservoir usually once every twenty-four hours.
    The changes in the physiological action from the vigorous, rapid motion of the enteron, to the moderate, slow movement of the colon and rectum, must be due to the intervention of the inferior mesenteric ganglion, located at the root of the inferior mesenteric artery, which emits its radiating branches along the inferior mesenteric artery, supplying the left end of the transverse colon, the left colon, the sigmoid flexure and rectum.  The right colon and the right half of the transverse colon are supplied by the abdominal brain, sending branches along the superior mesenteric artery.  Now, it is quite probable that the slow movement of the nerves belongs entirely to the left colon, sigmoid and rectum, which is entirely supplied by branches of the inferior mesenteric ganglia.
    Hence, for the regular periodic evacuation of feces, a habit established by ages, we must look to the immediate rhythmic control of the inferior mesenteric ganglion.  This is in accord with the idea that the stool, before expulsion, lies in the sigmoid and rectal ampulla.  That the portion of the bowel concerned in evacuation is under control of a nervous mechanism, may be inferred from the fact that a person can establish almost any definite hour for regular defecation.  A person can sometimes restrain the stool without difficulty for several days.  For the cause of constipation we must look to a peculiar nervous disturbance in the peristalsis, absorption, secretion, and sensation of the colon, or of that part of the colon supplied by the branches of the inferior mesenteric ganglion.
    In constipation the feces are found in the colon and not in the enteron.  This abnormality of the colonic innervation may be congenital, or acquired.  Some individuals are constipated from childhood.  A boy of fifteen came to my office a short time ago who had never had a stool from babyhood onward without a rectal injection, or some strong physic.  By careful examination it appeared that neither the cerebro-spinal nor the sympathetic system was fully or completely developed.  However, in a month, from physical procedures, select food, ample fluid at regular intervals, massage, rectal injections, vigorous riding and regular stool hours, we secured a habit of daily evacuation.  Here, doubtless, the trouble was congenital-deficient and imperfect development.   Depressing mental affections derange the regular bowel action. However, in constipation accompanying melancholia, or mental disturbances, it seems to me that it is impossible, at present, to decide which is the cause and which is the effect.  To illustrate the influence of the nervous system over bowel evacuation, observe how a railroad journey, a change of locality, festival and change of labor, affect a constipated condition.  Besides, autopsies of persons dead from other diseases teach that in constipation seldom can structural lesions be demonstrated.  The chief features of habitual constipation tend to show that the abnormal condition must be sought in a neurosis of the colon (especially to the left colon, the sigmoid and rectum).  The exact nature of the colonic affection is unknown.  Another factor in constipation is that though the nervous system of the colon be fairly developed, yet the muscularis of the colon is not normally developed.  There is atony of the colonic wall, well expressed by old Latin authors as atonia intestine.  But in this case perhaps the colon muscular atrophy refers to the nerves, as they control the lumen of the blood-vessel, which is the real nourisher and instigator of function.
    In regard to the relations of the skeletal muscles to the intestinal muscles, in constipation, we maintain that they are entirely independent of each other, except mechanically.
    The subject with the most weakened and miserable condition of the skeletal muscles may be absolutely regular in bowel evacuation, or may suffer severe constipation.  Of course, we must not omit the mechanical influence of the abdominal muscles in defecation.  The abdominal muscles increase the intra-abdominal pressure, and thus aid evacuation, but it is not likely that they increase peristalsis.  Perhaps in general the skeletal or intestinal muscles play but a small role in constipation.   The matter lies closer to the nervous system.
    Bouveret and Dunin have claimed that habitual constipation was a frequent accompaniment of general nervousness, especially of neurasthenia; that the neurosis was the constipation, not the constipation the cause of neurosis.  This idea is apt to prevail with most force among those physicians who, in curing the patient of the general neurosis, neurasthenia, have seen the constipation disappear.  Fleiner asserts that stool retardation is due to spasmodic contraction of the colon segments, grasping their contents.  This would make the trouble depend on the nervous system.
The mechanical conditions that induce constipation will not be here considered, except so far as their purely nervous mechanism and influence is concerned.  Hence, such factors as strangulation by peritonitic bands and through apertures, and the mechanical difficulties of splanchnoptosia and pressure of abdominal tumors, are not here discussed.  However, we must not overlook the obstacles placed in the way of the intestinal nerves by inflammation of any one of the bowel coats, or tunics, as peritonitis, or inflammation of the muscularis, or of the mucosa.  As abdominal surgeons, we well know that acute peritonitis produces immediate constipation, checking peristalsis by edema, congestion and exudation, into one of the bowel tunics, especially the peritoneum.  The peripheral bowel nerve apparatus is deranged by pressure, infection and malnutrition.  It may rapidly recover.  But, doubtless, a crippled and defective condition frequently remains - nonmechanical.  As a result of peritonitis or inflammation of any one of the bowel tunics, producing habitual constipation, we must especially examine the flexura coli lienalis and the flexura sigmoidea.  Not infrequently the action of the distal end of the diaphragmatic muscles produces inflammation of the left colon, by inducing migration of microbes through muscular trauma.
    Also the conditions disturbing the rectal nerves must be considered as causing congestion and results.  In constipation we only include the colon segment supplied by the branches of the inferior mesenteric ganglion.  It must not be supposed for one moment that peritonitis around the evacuating fecal depository is always recognized. Far from it, for in some six hundred recorded adult autopsies I found evidences of peritonitis in the peritoneum of the left colon in fully eighty per cent of subjects.  In fact, in the esosigmoid alone there was about seventy-five per cent of peritonitis.
 

X-RAY OF DUCTUS BILIS ET DUCIUS PANCREATICUS .       Fig. 82.   This illustration suggests the quantity of nerves required to ensheath the ducts and vessels of the liver and pancreas as fenestrated, nodular plexuses.

    Constipation may arise in some persons from deficient or abnormally small abdominal brain, or from premature senility in the abdominal sympathetic, which innervates the gastrointestinal tract; also from cerebrospinal disease, which inhibits sources of energy.  Exhaustion, mental or physical, is a potent factor in constipation.  A deficient blood supply to the parenchymal ganglion does not invigorate it sufficiently to induce peristalsis.  Exhaustion from over-exertion, excessive sexual action, or extra loss of blood, is a common cause of constipation in young women.  Depression from disappointment, from death, from unrequited love, and many other causes, is quite apparent in the youthful, producing constipation - a purely nervous phenomenon.
    Constipation in lead colic is a nervous phenomenon, apparent in the intestinal pain, and in the white ring-like contraction of the circular bowel fibers.  The etiological factor is the irritation of the parenchymal ganglia of the bowel wall by the lead.  Spasm, irregularity of inertia, characterizes the bowel in lead colic, except in the etiology.
    Violent and persistent constipation depends on perverted muscular action, peristalsis, absorption, sensation or secretion, due in general to some deficiency of nerve force.  Colonic inertia may rest on deficient blood supply to the parenchymal ganglia, but this is directly under the control of the sympathetic, which holds sway over the vessel's caliber.
    It must always be borne in mind that the size of the sympathetic differs very much in different individuals.  When a small-sized visceral nervous system becomes impaired, as it easily will, its phenomena are not only marked, but difficult to correct.  A large dose of digitalis slows the heart, and whether the spinal accessory or vagus, digitalis inhibits its action.  Nothnagel suggests that opium works similarly on the splanchnics, i. e., by slowing peristalsis.
    The movements of the enteron are largely dependent on the amount of blood in the intestinal wall i. e., the amount of fresh blood which supplies the parenchymal ganglia.
    In regard to antiperistalsis, in scores of experiments on dogs, rabbits, guinea-pigs, etc., I saw no such a phenomenon.  The vomiting in ileus paralyticus or peritonitis maybe due to simple contraction of the stomach on the enclosed contents, when the fluids pass through the esophagus in the direction of the least resistance.  The monstrously large, wide cecum of herbivore, a vestigial stomach, as in the cow and horse, is emptied by peristalsis and not by antiperistalsis, as noted by Jreper.  It may be that the peristalsis is increased in diarrhea, yet it may be just as active in constipation, but in this the colonic movements are vain and futile, from inability to force the contents into successive new segments, for an empty bowel is a still one, and a full bowel is an active one.  Also active peristalsis will invite more blood into the bowel wall, which, in turn, induces active motion in the segments. Doubtless, herein lies the value of abdominal massage.  Whatever checks the flow of fresh blood to the bowel wall slows peristalsis, and this explains the constipation of anemia.
    The natural secretions, as the bile and the pancreatic fluids, are, perhaps, sufficient alone to excite the parenchymal, ganglia to action, with but little or no aid from the splanchnics.  Hence, from the inactive hepatic and pancreatic secretion, constipation may result.  Consequent swelling of the mucosa from catarrh, in the bile ducts, may exclude the bile from other channels, which would deprive the parenchymal ganglia of their accustomed stimulus.
    The relations of adjacent viscera and their condition may influence constipation.  If the accustomed secretions, bile, pancreatic and gastro-intestinal, diminish, the bowel will not receive the impulse which the normal amount of secretions impart, and peristalsis partially fails.  Diarrhea may be instigated by congestion, then by edema and, instead of infiltrating the bowel wall, the result may be rapid exudation and diarrhea.
    Increased peristalsis, however, is not necessarily accompanied by increased secretion and exudation.  The irritation which produces the peristalsis may so irritate the parietal intestinal ganglia as to lessen the caliber of the blood vessels and thus check secretion.  In administering certain purgatives it is found that they are followed by watery evacuations.  But this may be due to exalted peristalsis of the bowel, allowing insufficient time for absorption, e. g., in times of quiet peace in the bowel secretion and absorption balance each other; but if segments of the bowel become irritated by cathartics, the secretions may become very much increased.  Yet, owing to the vigorous peristalsis, the fluids are rushed distalward, not allowing sufficient time for, absorption.
    Constipation is generally a form of neurosis, which may partake of a sensory, motor of secretary nature.  It may, however, have a complex course and origin.  Constipation is a condition in which the colon is not evacuated daily, except by the aid of evacuants, rectal injections or physical procedures.  The great majority of the human family having a daily bowel evacuation establishes the normal frequency at once a day.  Exceptions to this rule may be observed in certain individuals who have two stools daily, others one stool in two or three days, while again Pick reports patients who have one stool a week.  A doubtful report was made by Dr. Robert Williams, where a woman had four bowel movements a year, three months apart.
    This irregularity or deviation from normal defecation, need not necessarily be based on demonstrable pathological conditions.  In constipation we have several elements to consider, the mucosa, the muscularis, the blood-vessels, the serosa, and the nerve supply.
    Perhaps the greatest etiological factor of constipation is enteritis, catarrh of the colonic mucosa.  This would involve the secretary nerves.  In fact, catarrhal diseases of the colonic mucosa are the active factors in ever-changing forms of constipation and diarrhea, which, doubtless, involve the secretary nerves more than the motor nerves.  Of course, the regularity of stool depends very much on the quality and quantity of food ingested, for if the food leaves no residue it will conduce constipation, for the greatest of all stimuli to colonic motion is food in contact with the intestinal mucosa.  The peripheral nerves of the intestinal mucosa receive impetus and sensation from the analward moving fecal remnants.
    The chief influence in constipation is the blood and food.  The formation of the stool depends mainly on the relation of the solids and fluids introduced into the stomach.
    A close relation exists in constipation between the quantity of food ingested, and the resulting fecal residue, which actively counts in treatment.  Water is one of the best adjunct evacuants.  An exclusively milk diet may create constipation, because the small residue is insufficient to excite peristalsis through the peripheral nerves.  If milk creates diarrhea, it is likely from some sudden development of germs, or fermentation.  The utility of graham bread in curing constipation lies in the fact that a large indigestible residue remains, inducing colonic contraction; its contained salts either invite fluids or excite peristalsis, both resulting in a kind of massage, or acting like a foreign body to the mucosa.
    The habits of life are closely associated with constipation.  Society women and traveling men, with irregular ingestion and habits, are liable to constipation.  Sedentary habits, deficient exercise and excessive mental work, tend to produce constipation.  The use of narcotics, deficient drinking of water, active perspiration and uncomfortable closets play a role in inducing constipation.  Excessive eating or excessive ingestions in the gastro-intestinal canal may lead to atony of the intestinal wall, and consequent constipation.  The causal relation of constipation must be sought in the digestive tract itself, in the quality and quantity of food ingested, in the habits, in the relations of other viscera.
In certain cerebro-spinal diseases, the sensory nerves of the intestinal mucosa may be obtunded or blunted, so that the ordinary peristalsis is not excited by the ordinary stimulus of food residue.  The peripheral sensory apparatus of the mucosa does not perceive the usual stimulus, and the bowels become torpid.  This is common in certains form of hysteria, or better, visceral neurosis.  In melancholics and hypochondriacs the barometer of their spirits seems often to tally exactly with the bowel activity.  The greater the activity of their bowels the more lively and natural their mentality.  But it must not be forgotten that constipation is often occasioned by the mental condition.  We know personally that vomiting may be induced by a physical cause, or by a mental one.  Some will vomit from seeing a fly in the soup.  So it is with a genital neurosis, it may create constipation, or may induce a local neurosis by bathing the innumerable ganglia with waste-laden blood.  If secretion be deficient, absorption continues, the feces harden, form an increasing plug, and becomes such an impediment that even vigorous peristalsis will not produce the analward movement required.
Heredity and congenital ailments play a role through the defects in the nerves of the intestines.  We deal here chiefly with the purely nervous influence, as the intestinals of the cachectic may be confined, or may act very irregularly.  Persons with defective nervous systems, as idiots and the insane, suffer from constipation.  The ill-defined hysteric person, or the neurotic subject, is painfully afflicted with constipation, with sluggish bowels, and some of these very subjects are continually complaining of colicky pains, which are to be interpreted as vain attempts of peristalsis to force the bowel contents analward.
    In constipation splanchnoptosia plays its role by flexing the intestine, producing conditions which require more vigorous peristalsis to overcome; in short by compromising the bowel caliber.  In splanchnoptosia the hepatic and splenic flexures are both made more acute by the consequent dragging of the ligamentum hepatico-colicum et phrenico-colicum sillistrum.
    Relaxed, pendulous abdominal walls are incapable of exerting normal or sufficient pressure on the tractus intestinalis to control circulation (lymph or blood) or to expel the feces.
    The fecal reservoir, as previously stated, is the left half of the transverse colon, the left colon, the sigmoid and rectum, the field ruled by the inferior mesenteric ganglion.  It has been asserted by my respected teacher, Nothnagel, that constipation is relatively frequent in comparison with the rarity of peritoneal fixation.  I wish respectfully to differ from this excellent and instructive Viennese teacher.  In some six hundred personal autopsies I found peritonitis in the fecal reservoir in at least eighty per cent of the subjects.  This peritonitis, due to two causes, viz., traumatic muscular. action of the psoas magnus on the sigmoid, and of the distal left limb of the diaphragm on the left colon, which induces migration of pathologic microbes to the serosa; and the abrading of the mucosa of the fecal reservoir at the flexures (splenic and sigmoid), allowing the wound to become infected, and the migration of pathogenic germs to the serosa.
    Nowhere in the body is infection from the mucal abrasion more definite than at the ligamentum phrenico-colicum sinistrum.  In six hundred adult autopsies we found that the fecal reservoir was afflicted with peritonitis in more than eighty per cent of the cases.  Did eighty per cent of these cases suffer from constipation?  We think not.  Therefore, according to our six hundred autopsies, peritonitis of the fecal reservoir is far more common than constipation, for eighty per cent of adults do not suffer from constipation.  Hence, we are forced to the opinion that peritonitis of the fecal reservoir has undoubtedly an influence in inducing constipation, by traumatizing the nerves presiding over defecation.  The nerves may suffer from pressure by exudates or edema, from congestion or malnutrition.  The final outcome is derangement of the nerves of the fecal reservoir - exaltation or debasement of sensation and motion.  As probability is the rule of life, the results of peritonitis of the fecal reservoir is here referred to, and not acute peritonitis.  I have shown (Peritoneal Adhesions After Laparotomy, Amer.  Gyn. and Obstet. Jour., December, 1895) that gross peritoneal adhesions (bands) attached to organs of maximum peristaltic action, as the middle of the sigmoid flexure and the oviducts (or their amputated ends), the mobile bladder, or the active peristaltic loop of enteron, frequently create very much pain, though not necessarily constipation.  Yet the finer pathological infiltrations, perhaps, not even microscopic, or at least insufficient to create condition of the fecal reservoir which may be far more effective in causing constipation, than the gross peritoneal bands which simply fix, dislocate viscera, or parts of viscera, are an important factor in inducing constipation in splanchnoptosia.  Perhaps splanchnoptosia should be viewed as a constitutional disease, a general neurosis.  The viscera supports very gradually elongate in splanchnoptosia, and the nerves as gradually lose their tone.  That the visceral nerves are involved in splanchnotosia is very evident from the manifest derangement of the nerves of sensation, motion, absorption, and secretion.  Splanchnoptosia is a weakening of the nervous system, a special slackening, or elongation of the visceral supports, which we must acknowledge is not manifest in the digestive tract muscles, but attacks the skeletal muscles (e.g., of the abdominal wall).
    Every practitioner has observed that with the induction of habitual constipation a peculiar nervous phenomenon also arises.  The popular opinion is that the constipation is the cause of the neurosis, but such an opinion does not always stand the test of analysis.  Is the neurosis not the cause of the constipation?  The finer beginnings of the neurosis was not observed, while the grossness of constipation is discernible form the beginning to end.  After constipation has once started, a train of symptoms may set in, as long  retention of the feces allows them to become dry and hard from absorption of fluids.  The feces becomes pressed into the saccules of the colon, a hard, irregular  masses, known as scybala.  Such masses, by continued pressure, may produce mucus ulceration.  The subject experiences fullness in the abdomen and disagreeable sensations; the appetite disappears, gases are eructed, and a disagreeable taste arises.  The skin may assume a muddy color, and the fecal masses may be covered with mucus in various quantities.  Some practitioners falsely attribute the lime, or mucus, to colonic catarrh.  The excessive mucus is due to irritation of the mucosa by the fecal masses, which irritation may also induce a hyperemia of the mucosa, producing disordered secretion, with fermentation and gases.  The fecal accumulation can produce not only a transitory mucal hyperemia, excessive secretion and diarrhea, but anatomic changes, such as colonic catarrh, trauma of the colonic wall and local peritonitis.  Considerable colic may arise from the attempts of the colon to expel the large accumulated masses, which palpation may reveal.
But, to speak of the difficulties arising from hardened masses of accumulated feces is only to bring in mechanical difficulties, with all their train of evils, on the three tunics of the colon and their functions, which is not our chief theme.  Our contention is that constipation is a neurosis of the fecal reservoir.
To illustrate how intimately the nervous system rules the fecal reservoir in its periodic evacuations, all that is necessary is to recall how many patients relate that, on change of business, residence, or scenery, the evacuations being neglected, cease their regularity.  So far as I am aware, constipation always has one of its results, the collection of feces in the colon, from the rectal ampulla to Bauhin's valve, but the chief locality is the middle of the transverse colon to the rectal ampulla.  The collection of fecal masses in the right colon is rare, and, perhaps, in the right half of the colon it is also rare, except from mechanical causes, i. e, if half of the colon be full of hardened feces, the right half will be full, from the physical fact of its inability to force them analward.
    The train of evils resulting from constipation is almost endless, e.g., the fecal masses produce pressure on the returning veins of the fecal reservoir, causing congestion, especially in the rectal veins, resulting in hemorrhoids.  Perier has recently attempted to show that the so-called "fecal fever" is due to absorption from the digestive tract.  The proof of this he demonstrates by a cathartic reducing the fever.  This view of Perier has some show of truth in it, for in puerperal sepsis, in fever after operation, a cathartic reduces the fever like a charm.  The drain by the cathartic directs the poison outward.  However, it must be remembered that high temperature subsequent to some pelvic operations, is rather due to absorption of septic matter remaining in the pelvis than absorption from the bowel.  For long past and even today certain widespread opinions, in regard to certain definite connections between the central nervous system and constipation exist.  Constipation and the central nervous system are brought into close relations.  All grades of symptoms, from the slightest disturbance to hypochondrical and severe Psychical, are included as due to constipation.  Certain writers have tried to show that relations exist between dyspepsia and constipation on the one hand, and hypochondria and melancholia on the other.  Virchow started such views nearly fifty years ago, and Virchow always wrote with a pencil of light.  The celebrated neurologist, Romberg, claimed in 1850, that constipation could induce hypochondria.  It is not strange that the opinion of such giants as Virchow and Romberg, both strengthened by observations, should prevail so long.  But our belief is that constipation is a neurosis of the fecal reservoir.  Hence, constipation, melancholia, and hypochondria are the result of neurosis, and not the cause.  We must look to neurasthenia as the forerunner of constipation, as the neurotic invader of the fecal reservoir bringing in its wake constipation.  When neurasthenia and melancholia enter, the process becomes retarded.  Recently, Dunin has favored the view that constipation is the result of a neurosis and not the cause.  True it is that nervous persons do not always suffer from constipation nor are non-nervous persons invariably free from it, but, first, be it remembered that the fecal reservoir is chiefly under the influence of the inferior mesenteric ganglion, and its radiating nerves (sympathetic), and not the cerebro-spinal, though the last-named exercises certain influences over the fecal reservoir; also, that the fecal neurosis is a local affair, i. e., the peripheral nerves supplying the colon in area of the inferior mesenteric artery may be attacked by disease, independently of the remaining sympathetic and cerebro-spinal systems.
    The general view here entertained in regard to constipation and neurosis is: That the constipation is the cause of nervous symptoms, e. g., a person suffers for several days from constipation and light cerebral symptoms arise, as headache, dizziness, pressure in the head and inability to think well.  There may be feelings of heat in the head and considerable general languor.  The urine may be a little scanty and high-colored, with hot and dry skin.  There is often slight respiratory disturbance.  Physicians generally attempt to prove that all these cerebral symptoms depend on the several days of constipation, from the fact that after a brisk cathartic the cerebral symptoms disappear.  This circle may be, and often is, repeated in the same individual.
    At first sight this explanation, with its practical demonstration, seems very laudable.  But is it satisfactory?  Can not the neurosis, the subjective light cerebral symptoms, be the cause of constipation?  It is not easy to give a categorical proof of this.  The disturbance, or hindrance, in respiration and circulation may find an explanation in the elevation of the diaphragm.
    The cerebral circulation may be disturbed by the reflex irritation of the abdominal viscera, transmitting the irritation by way of the lateral chain of the sympathetic and the splanchnics.  Leube has recently reported cases where the person became dizzy from pressure in the rectum, either by fecal masses, or by the finger.  Here the dizziness arises from irritation of the hemorrhoidal plexus of nerves.
    Again, Senator suggests that the absorption of certain gases, as sulphureted hydrogen, might induce poisonous symptoms.  Nothnagel suggests that in constipation ptomaines might be absorbed, inducing cerebral symptoms.  But Bouchard demonstrated that toxic fecal ptomaines may occur in fluid feces, as is seen in the large amount found in the urine of patients afflicted with diarrhea.  Again, the cerebral symptoms depend on the constipation.  Is the argument the same with melancholia and hypochondria?  Does it depend on constipation?  In other words, does constipation cause, in otherwise healthy persons, hypochondria, or other psychoses?  We think it does not.  The proposition should be made in two forms:
    (a)  Constipation may occur in otherwise healthy persons.  These, we claim, do not suffer the hypochondria and psychoses.
    (b)  Constipation occurs in patients with a neurotic tendency.  These last are the subjects which suffer from melancholic psychoses during constipation.  It is undeniable that psychical depression may develop during constipation in certain persons, but they are of the neurotic type, and in these the abdominal disturbance of the bowels would similarly affect (as disturbances in any other functions) the weakest point, i. e., the part of the animal economy which resists the least.  Single-handed and alone constipation does not create hypochondria and melancholia, but in a system burdened with neurotic tendencies, with unstable nerves, they may exist, but are, perhaps, the cause of the constipation.
    Virchow says the following: "Das bei einer gewissen erregungs fahigkeit widerstands losigkeit (predisposition), des nerven apparatus storkungen mit dem character der exaltation an den sensitiven und dem der depression und den motorichen nerven herrufen."  Freely translated it is, "That by certain tendencies (non-resistance, predisposition) of the nervous apparatus, disturbances of the abdominal viscera may produce the character of exaltation in the sensitive nerves, and depression in the motor nerves."
    It appears to me, however, that the popular professional idea of the effect of constipation on the brain is exaggerated, and much of the belief is untenable.
    The celebrated English author and physician, Dr. Barnes, held that constipation was the cause of chlorosis.  Perhaps this view arises from the supposed fact that some of the chlorotic girls recovered after cathartic treatment.  But, since chlorosis is a disease of a certain age, i. e., from fifteen to twenty-five years, such a fact remains to be proved, for the constipation accompanying chlorosis constitutes but a small portion of the ailments atacked by it.  Constipation and neurosis are, nevertheless, close relatives in many subjects with peculiar nervous symptoms.
    The relation of the gastro-intestinal canal to other viscera is of prime importance as modifying peristalsis.  The emphysematous lungs force the diaphragm distalward, and this destroys the tendency to free peristalsis.  Heart. liver and kidney diseases, if they produce congestion in the bowel coats - serosa, muscularis and mucosa - will lessen peristalsis and consequent fecal motion.  Diabetes induces constipation by diverting fluids from the intestinal tract, and the consequent drying of the feces.  In the chlorotic and anemic it is difficult to distinguish cause and effect.  They are both constipated.  But the retardation of fecal movements may be followed by anemia and chlorosis, or auto-intoxication.  However, chlorosis belongs to females, in general, from puberty to the age of twenty-five.  It is a developmental disease.  In fevers deficient peristalsis induces constipation.  Excessive sweating, also, renders the feces dry, and the diminution in the amount of food taken leaves less residue to stimulate peristalsis.
 

X-RAY OF DUCTUS PANCREATICUS ET DUCTUS BILIS       Fig. 83.  The pancreatic and liver ducts, ensheathed by a network of fenestrated, nodular nerve plexuses.  Also the portal vein.

    Fleischer suggest that in fevers the high temperature of the blood bathing the ganglia in the walls of the bowel tends to inhibit peristalsis, and hence cause constipation.
    Under sympathetic nerve influence we are not including constipation from mechanical factors, as volvulus, flexions, obstruction by peritoneal bands and through apertures, pressure from tumors, strictures, or dislocated organs.  Experience teaches emphatically that enteritis, or catarrh of the enteron, induces constipation.  If catarrh of the colon and enteron exists, diarrhea and constipation will generally alternate.  The secretary, as well as the motor nerves, are highly involved in catarrh.  Ulcerative processes in the mucosa inducing diarrhea are not included in nerve influence.  We, of course, have constipation in atony of the bowel wall, as well as in partial paresis.
    Bowel weakness arises in potators, tabetic and tubercular patients, and in those with progressive splanchnoptosia.
    It is plain to any one that a neurosis acts in various ways on the tractus intestinalis, influencing constipation or diarrhea.  The hysteric and neurasthenic both suffer from irregular constipation.  It is a common observation that patients who complain of abdominal neuralgias suffer more or less from constipation.  It appears as if the nerves of the bowel do not work in harmony, the bowel is incapable of regularly emptying itself.  Besides, neuralgia is, doubtless, a malassimilation of a sensory nerve, and since the sensory and motor nerves are complements of each other, they must work in harmony to accomplish an object - evacuation.  The bowel contents irritate the periphery of a sensory nerve in the mucosa, this is carried by the organizing ganglia of the muscular wall, which induces muscular motion.  The blood vessels of the bowel wall exert vast influence over peristalsis, and the vessels are ruled by the sympathetic nerves.  With deranged nerves of the intestines there will necessarily be deranged circulation, and either congestion or anemia induces a lowering of peristalsis - constipation.  The circulation on the surface of the body is only an index of what is occurring inside.  Now, it is common in neurotic persons to observe a dozen marked changes in the superficial circulation in a single day.  The changes of circulation affect the bowel wall in a similar way that they do the surface.  The effectiveness of circulatory changes is, perhaps, best observed in the serous covering the bowel, as in peritonitis, where constipation exists.  In peritonitis the bowel wall becomes edematous, congested, and the peripheral nerve apparatus is compromised by pressure and malnutrition, so that we always expect constipation in peritonitis.  The circulation is deranged.
In the territory of the secretary nerves, which belong to the sympathetic, as well as the motor and sensory nerves of the intestines, a vast field lies unopened.  At ordinary times secretions progress in definite proportions, but, pathologically, we have excessive, deficient, or disproportionate secretions, e. g., there may be excessive bile, HCL, gastric or pancreatic fluids, or all of these may be deficient.  Again, the bile may be secreted in proper amounts, so that we would have disproportionate secretion, which induces fermentation, the development of gases, tympany, and the undue development of certain microbes.  If deficient HCI, or bile, be secreted, both of which are antiseptic, microbes develop.  Also, it must not be forgotten that deficiency of secretion checks peristalsis, whether it be deficiency of bile, pancreatic, or other gastrointestinal fluids, and slowing of peristalsis invites constipation.
    To illustrate the influence of nerves over peristalsis, observe how the irritation of a small fissure will induce constipation, first by abstention from stool and, second, by breaking the regular habit of stool.  By forcible dilatation of the rectum the regular stool habit assumes its old course.  In the case of anal fissure the irritation is purely reflex on the remaining portion of the gastrointestinal canal.  It would appear that constipation, in certain forms, may be well remedied by daily dilatation of the sphincter.  This dilates and flushes its peripheral capillaries.  Dr. Bier reports successes in the Wiener Med. Blaetter, l891, No. 25.
    The complex symptoms of constipation may be indecisively divided into general and local symptoms.  The general and most disastrous symptom is that of auto-intoxication.  It represents a series of manifestations in the territory of the nervous system, whether it be chronic or acute, common symptoms or headache, dizziness and neuralgias about the abdomen, as well as sleepiness, melancholia, languor, a feeling of debility and nausea.  Pick says the visible expression of the constipation is the richness of excretory principals in the urine, and the increased toxicity of the same.
    One of the local symptoms of constipation is the feeling of fullness and pressure in the abdomen, which is generally distended.  The passage of gas gives temporary relief.  The diaphragm is forced proximalward, compromising the heart, so that it not infrequently palpitates, and the lung manifests difficulty in respiration.  In certain cases considerable colic is produced at stool, from irritation of the bowel wall by hard fecal masses.  The positions of local colic from expelling hardened feces are the ampulla of the rectum, the cecum, the hepatic and splenic flexures, the middle of the transverse colon, and S-romanum.  Large, hard, rough fecal masses not only cause much pain, but they abrade the mucosa and finally produce ulcerations, which heal slowly.
    Visceral Circulation in Constipation. - The proverbial advice of the elderly doctor, when he wishes to be social, entertaining and instructive, is to keep the head cool, the feet warm, and the bowels open.
    This philosophic advice is frequently theoretical, rather than practical, from an application to the actual living habits of the subject.  In the present modes of living among women constipation plays an extensive and damaging .role.  The evil effects of constipation extend to adjacent visceral tracts, as circulation, respiration, and particularly on the tractus glandularis - secretions.  The most important visceral tract of life itself is the tractus vascularis, over which the sympathetic nerve, nervus vasomotorius, maintains direct control.  An ample stream of fresh blood can not properly irrigate constipated visceral organs.  In constipation one or more of the four great common visceral functions - peristalsis, secretion, sensation or absorption-are disordered.  The disturbance of circulation in constipation may be. local or general.  We observe the profound anemia of girls, frequently following the phase of puberty.
    The circulatory changes are at first local, later general.  The anemic, chlorotic girl (from fifteen to twenty-five years of age) is plump, fat, and beautiful - in fact, it is the anemia of the good-looking girls.  It appears concomitant with the disordered local circulation (genital); the later, general, disordered circulation, is accompanied by disordered, hypertrophied glandular system (tractus lymphaticus) and constipation.  The chlorotic girl might profitably pose as an alabaster or marble statue.  Hence, disordered circulation (pubertas), accompanied by disordered general circulation, disordered tractus lymphaticus, and constipation (disordered peristalsis, or secretion, or absorption).
    In the establishment of menstruation numerous local (genital congestion or anemia) or general (chlorosis) circulatory disturbances arise.  In pubertas the luxuriant vessels (veins) of the ovary and its compensatory balanced arm, the endometriuin, become congested, engorged, which robs the blood from the tractus intestinalis and disturbs not only local, but general circulation, which condition is intensified in gestation.
    Until the habit of menstruation is established the local change of circulation may induce constipation.  In fact, I have relieved numerous gynecological patients by restoring normal evacuations of the bowels, and vice versa, normal genitals may restore normal bowel evacuation.
In short, detailed attention to the circulations - a matter directly under command of the sympathetic - is one of the most important factors in regulating constipation.
    It is the detailed study of sanitorium patients, as to life, habits, diet and fluids, that makes the sanitorium financially profitable and suggestive, at least to the so-called surgeon who is so busy with major operations that he walks over gold and silver daily.  The neglect of accurate diagnosis and consequent neglect of detailed treatment and defects of common functions, constipation, by the physician, is the reason of the multiplication of sanitoria, and the consequent loss of feces and confidence in the home physician.
    It is the duty of the physician in defects of the common visceral functions - peristalsis, absorption, and secretion - to introduce visceral drainage to relieve the patient of waste-laden blood, and restore normal circulation.  The physician should decide in detail the quality and quantity of the food and fluids ingested, and determine the methods of sewerage.  He should recognize the secretary and motor activity of the tractus intestinalis, and the fascio-elastic muscular apparatus of the abdominal wall, which aids in evacuating the bowels.
    Women, especially the young, must be taught the absolute necessity of regular daily evacuations, regardless of environments, time, place, views, or agreeability.  The woman should know that exercise, muscular activity, is necessary for the abdominal muscles to force continually the bowel movements, contents, analward.  Active bodily movements, fresh air, bicycling, walking, aid very much to maintain visceral circulate on.  Artificial checks to respiration, as the corset or tight bands, check circulation, especially visceral, and hence peristalsis, absorption and secretions of the tractus intestinalis is checked.  The corset is an enemy to circulation, and a friend to constipation and is unhesitatingly condemned.
    Only ocular demonstration will convince a woman against corsets, so firm has become the senseless iron rule of fashion.
    To illustrate the important influence of circulation in constipation, the first week of marriage may be noted.  The extra irritation of the genitals induces a genital hyperemia, a congestion which robs the blood from the tractus intestinalis, leaving in its ivake intestinal paresis - constipation.
    Menstrual disturbances, chronic genital inflammation, entice blood from the tractus intestinalis, leaving defective intestinal peristalsis from lack of blood.  Removal of chronic congested genitals may restore normal action of the genital tract by returning to them their normal blood stream.  Not only does pregnancy induce constipation by enticing a continual blood stream toward the genitals from the intestinal tract, but in the puerperium the abdominal muscular apparatus has lost its original elastic tone, its power of compression.  The enforced corporeal rest and non-irritating food administered engenders a constipation by disordered, unbalanced circulation.
    In the puerperium, instead of an abdominal binder, the abdominal muscles should be massaged.  The patient should practice on the abdominal muscles gymnastic exercises, in order to quickly restore them to normal action, and thus avoid one of the prime factors of splanchnoptosia.
    The abdominal binder, the enforced rest, and concentrated food in the puerperium, all tend to lessen the visceral circulation, especially in the intestinal tract, and hence to entice constipation.
    The Diagnosis of Constipation. - First and foremost an examination, extending from mouth to anus, is a prerequisite to diagnose constipation.
    The mouth, and especially the teeth, unfold an important story.
    The state of the abdominal and thoracic walls are significant.  Does splanchnoptosia exist with its general consequences?
    What is the state of the rectum (fissure, hemorrhoid, ulcer?) is of extreme importance.
    The tractus vascularis tells its own story in arteriosclerosis, which would indicate defective circulation in the splanchnic area.
    Careful palpation of the plexuses and connection cords of the abdominal sympathetic should be practiced, as they regulate the caliber of the splanchnic vessels.  Tenderness of the abdominal sympathetic plexus indicates an irritable condition of the viscera.  If marked sclerosis exists, the abdominal aorta is palpable and tender.  It is enltrged, movable, and pulsates vigorously, The tendernesss is to be localized especially along the plexus aorticus distal to the umbilicus, and in the plexus celiacus (abdominal brain) proximal to the umbilicus.  This tenderness indicates a neuritis of the sympathetic, or vasomotor plexuses.  Colic, due to spasm of vessels (arteriosclerosis), must be differentiated from colic due to enteritis.  In neuritis of the sympathetic plexuses, the pain and tenderness is localized in the celiac and aortic plexuses, and along the route of the ensheathed, which is characterized by spasmodic and periodic exacerbation.  Peritonitis announces a more diffuse tenderness. and it is less spasmodic and periodic.  Enteritis presents tenderness, localized in the course of the enteron, and is accompanied by other symptoms, as mucus in stools.  The diagnosis of constipation is a small factor in practice, but the finest head, with the best skill, is required to diagnose the etiology, for on the cause of this malady rests the successful treatment.  It is needless to say that a thorough and complete physical examination is absolutely necessary.  For constipation may depend on the kind of food taken, on habits of life, on drugs employed, or on defects in the system.  Some affirm that heredity plays a role in constipation; however, this is only a cloak to cover what we do not know.  Many persons who have only one stool in two days, and remain healthy, are not constipated, and require no treatment.
    Treatment of Constipation - General Remarks. - First and foremost in the treatment of constipation, should be considered the diet.  Some physicians have a diet list.  In certain cases it is convenient, but generally of little value.  Oatmeal and graham bread, with milk as a beverage, leaves ample residue to induce peristalsis, which soon overcomes constipation.  In such cases, also, a few daily colonic flushings aid wonderfully, with the establishment of a regular hour for evacuation.      Especial stress should be laid on the matter of avoiding cathartics; they are among the chief causes of constipation.  The best methods of curing constipation are those which imitate nature the closest, and most perfectly.  They are, in order:

    1.  The regulation of diet (ingesta).
    2.  Physical procedures.
    3.  The judicious use of laxatives.

    In the regulation of the diet several factors are requisite, viz., food which leaves a large residue, which will impart the necessary constant stimulus to successive bowel segments.  Peristalsis requires a physical stimulus, a bolus that will feel its way from stomach to anus.  The diet should be a mixed one of cereals, meats and fruits, as well as concentrated foods.  It should be eaten at regular, fixed hours.  The bowel is an organ wonderfully inclined, in certain persons, to assume sluggish, stubborn habits.  Subjects who eat irregularly are apt to become just as irregular in evacuation.  To show the effect of the habit, observe how much more women are constipated than men - a result of insufficient physical exercise, or sedentary life.  Also, ample fluid should be taken with the foods.
The good effect of graham bread is chiefly due to the large residue, and the contained salts - both acting physically on the bowel, causing peristalsis.  The habits of the use of narcotics, drinking, smoking, chewing, and taking of morphine, sexual abuses, over-mental activity, etc., should be modified.
    The second method of treatment in constipation is the use of some physical procedure.  Of these several are important.  Among the first is the establishment of regular habits of evacuation and overcoming irregular ones.  The bowels should be evacuated every morning after breakfast, i. e., after drinking hot fluid and eating hot food.
    Heat starts peristalsis.  The mental state has much influence over the bowels, so that if the mind is set on a distinct hour for an evacuation, it is pretty sure to be secured. Another valuable factor is regular and vigorous daily exercise.  The most natural are walking, horseback or bicycle riding.  The habit of exercise is nearly always sufficient to overcome constipation.  Gymnastics serve a similar object.
    When the above exercises are not performed, one of the sovereign cures of constipation is voluntary cultivation of the abdominal muscles, or massage; at first, weak or light rubbing should be employed once or twice daily; subsequently, vigorous massage should be carried on.  Stroking, rubbing, tapping, kneading and gripping the abdominal wall should be judiciously performed.  The large intestine should be massaged from cecum to rectum, following the line of the colon, and the direction of the fecal current.  Rolling a bag of shot or dry sand over the abdomen is effective, if continued many days.  Much patience on the part of both physician and patient will be required to continue the massage, for it may need a month to accomplish permanent results by this process.  Rolling on the abdomen for ten or fifteen minutes every morning accomplishes goods results in constipation.  Another excellent remedy for both its mental and physical effects, is electricity.  Either the galvanic or the faradic current is effective.  The muscle walls of the abdomen can not only be treated by electricity, but one of the electrodes may be inserted into the rectum.  Another physical procedure of great value for a limited employment in constipation is irrigation, or colonic flushings, or rectal injections.  However, rectal injections blunt the sensibility of the rectal mucosa.  For mild cases a rectal injection of one-half pint of plain or salt water is sufficient to irritate the bowel, and excite an evacuation.  In more stubborn cases a quart of water, containing irritants, may be injected, by a fountain syringe, held two feet above the patient, and allowing the fluid to flow into the bowel.      Another method is turn a chair upside down, place a quilt over it, and then place the patient over this inclined plane, with the hips well elevated, and shoulders well down.  Then allow a quart of water (containing desired ingredients) to gradually pass into the colon.
    Besides the water injections, one may employ stimulants, such as epsom salts, olive oil, glycerine and water, at different temperatures.  An excellent rectal injection is a half pint each of molasses and milk.  It is hygroscopic.  The irrigation is accomplished with more safety and efficiency with the fountain syringe at a low level, e. g., about two feet above the patient's hips.  Cold fluid injections excite the bowels; however, warm fluids dissolve feces more rapidly.
    Olive oil treatment. - Constipation is benefitted by persistent course of administration of olive oil for a period of months.  I ordered a tablespoonful after each meal.  The chemical action of the olive oil is a result of the separation of the oil by bile and pancreatic ferments.  Through the bile and pancreatic fluids the fatty acids and soaps are produced which exert a mild chemical action, inducing evacuation.  To soften and dissolve fecal masses olive oil is excellent.  The value of the olive oil employed per rectum is dependent not only on its physical properties as softening and dissolving feces, coating and protecting the mucosa, and diminishing the absorption of water, but also on its chemical action.
    To produce an immediate stool, a cold-water rectal injection of one-half a pint will be the most effective, as it at once induces active peristalsis.  This may be added by rolling a bag of sand or shot over the abdomen.  Daily dilatation of the rectum, especially when it is inclined to spasm, or is subject to fissure, ulceration or hemorrhoids, is a usual procedure.  However, fissures, ulcers and hemorrhoids are proper cases for operations.
    Finally, in the treatment of constipation, we come to use of drugs - at once the most disastrous and inefficient of all methods.  Cathartics are to be avoided as much as possible in constipation.  Constipation is generally the result of catarrh.  Cathartics influence catarrh injuriously by further complicating the circulation, and inducing congestions and depletions.  In the treatment of diseases peculiar to women, which I have diligently followed for twenty years, and where constipation is a common matter, I seldom advise a cathartic, pure and simple.  The method I have followed successfully for years is what I term visceral drainage, presently to be described.  Drastic cathartics are the friends of constipation.  The number of cathartics is very great.  The choice of one will depend on whether the drug is intended for long or short use.  If a cathartic be employed for a short use, to secure an immediate evacuation, one of vigorous nature should be selected.  For this purpose none are superior to mild chloride, followed by magnesium sulphate.  The mild chloride stimulates the whole gastrointestinal glandular apparatus, while the magnesium sulphate induces a large flow of fluids into the bowel.  I have used these cathartics thousands of times, and have not yet observed superior ones.  The violent, drastic cathartics, such as croton oil, podophylin, colocynth and elaterium, are seldom required.
    Should a cathartic be required for prolonged use, one of a mild nature should be selected, such as rhubarb, magnesium sulphate, senna, aloes and cascara sagrada.  Drugs administered for chronic constipation should be employed at night, so that the quietude of the patient will allow the drug to pass slowly over the whole mucosa.  I am of the opinion that the addition of belladonna to cathartic pills is superfluous, and therapeutically only adds injury to insult.  The cathartic insults the mucosa, while the belladonna injures it, by attempting to deceive it by anesthesia-both enemies to the normal, peaceful, mucosa life:
    The beneficial effects of mineral waters, which generally depend upon the contained glauber and epsom salts, are only secured by long-continued use.  Of the two forms of drugs, pills or liquids, given for constipation, the pill form is the superior one, because it works slowly, and thus imitates nature more closely.  Nature always resents violent insults, with evil consequences.  Nature itself is a bundle of habits, and if we are to be successful, we must imitate her methods.  Hence, we must employ for constipation, diet, fluid, exercise, physical procedure, and, lastly, adjuvant cathartics - we must study the sympathetic nervous system.
    The treatment of constipation does not consist in searching after and administering drugs, but rather in the avoidance of their use.  We may first say that constipation is not curable by any planless method, nor by any planned method imperfectly executed, while there may really be non-removable anatomical conditions causing the difficulty.  Planless prescribing of cathartics is worse than useless.   The head and front of all therapeutics in constipation is due to an original, abnormal, nervous suspension of the peristalsis of the fecal reservoir.  This concerns us and our therapeutics; though we may find difficulty in excluding congenital defects, such as atony of the bowel wall, or constipation due to dislocated viscera.  Is the constipation, as Dunin suggests, a mere symptom of neurasthenia?  If our original proposition be true, viz., that constipation is a neurosis of the fecal reservoir, cathartics are not only useless, but harmful.
 

X-RAY OF DUCTUS BILIS ET DUCTUS PANCREATICUS OF HORSE       Fig. 84.  Bile and pancreatic ducts of horse which possess no cholecyst or gall bladder.

    In constipation we should attempt to cure the neurosis, the neurasthenia, when the constipation will disappear.  The moral part of the patient should receive attention, for often there is far more in the suggestions added to medicine, than the remedies themselves can supply.  If constipation depends on suspension of peristalsis, either from muscular atony or deficient innervation, it is plain how malpractice resides in the use of cathartics.  Physical procedures must above all be employed in muscular atony, or defective innervation, of the fecal reservoir.  In the treatment of constipation it may aid to determine the etiologic cause, as atonic constipation, associated muscular atrophy; neurotic constipation, associated with disorders of the cerebro-spinal axis or the sympathetic (tabes, lead poisoning); metabolic constipation, associated with disordered metabolism, as excessive obesity, sweating, diabetes, anemia; trophic constipation, associated with subjects ingesting excessive meats or other dietetic errors.
    Suggestion. - I wish here to emphasize the subject of suggestion in the control or cure of constipation.  The control of mind over matter has no uncertain sound in the aid to cure constipation.  The psychic effect of a well-directed suggestion is of ten effective in stimulating peristalsis for regular stated times for evacuation.  For example, tell a patient, definitely, to go to stool after breakfast, as the hot coffee stimulates the bowel to action.  He will not only concentrate his mind on the function, but will cultivate his mind for a definite period for evacuation, which I consider of vast value.  Occasionally, particularly in neurotics, this will effect a cure.  With the suggestion for a daily evacuation at a stated period should be combined simple convenient remedies, as gymnastic exercise, special diet, in order that the patient may observe cause and effect.
    Dietetic Summary - Quality of foods, quantity of fluid, chemical composition, are important considerations. (a) Food must possess sufficient variety (mixed)'in quantity, quality, chemical composition, and be ingested at regular intervals.  The food should be mixed, however, possess sufficient indigestible matter to leave ample residue to stimulate peristalsis (and hence absorption, sensation and secretion).  An excessive amount of coarse, indigestible food will result in an excessive fecal residue, which excessively stimulates peristalsis, absorption, secretion and sensation - resulting in muscular fatigue and defective sensibility of the mucosa - consequently, reflex action is impaired.
(b) Ample fluids, at regular intervals, should be ingested.  For a person of one hundred and fifty pounds five pints is required to supply the bodily waste (i. e., tractus intestinalis, respiratorius, urinarius, perspiratorius), eight ounces should be drunk every two hours for six times daily.  Fecal matter is about seventy-five per cent fluid and twenty-five per cent solid.  The value of fluids for the tractus intestinalis is evident, because in hot weather, with consequent vigorous action of the tractus perspiratorius, constipation results.  The chief value of mineral water is the quantity drank.  Excessive fluids deteriorate digestion.
    (c).  Foods should possess chemical qualities.  Carbohydrates produce acidity, nitrogenous foods alkalinity, and mixed foods neutrality of the digestive tract.  Evacuation of the tractus intestinalis depends on: (a) Sufficient volume of feces, (b) sufficient volume of fluid contents, (c) the presence of substances which act as a chemical irritant to peristalsis.  Dr. Walter Baumgarter attempted to devise a substance which would not only be difficult to absorb, but would retain its watery contents (be hygroscopic).  He administered eight grains of the dry, shredded agar-agar three times daily, whence he found the stool increased in volume and watery contents.
    Visceral Drainage. - I wish here to introduce a method of treatment for constipation which I have employed successfully for a score of years.  I have termed it "Visceral Drainage."
    One of the most important principles in surgery is ample drainage of (septic) wounds.  One of the most important principles in internal medication is ample drainage of the viscera.  Fifteen years of the application of what I term "Visceral Drainage," in dispensary and private practice, has afforded me ample time to observe its extensive application and utility.  Viscera are drained by several means; however, the two most rational and practical methods of visceral drainage are: (A) by fluids; (B) by appropriate foods.  The viscera are the sewers of the body, and their proper drainage and flushing is the key to health and its maintenance.  Draining the viscera drains and flushes the internal tissue and tissue spaces.
    The muscles are powerful regulators of circulation (as exercise), hence there is stimulation, which increases the tone of vessels, blood currents, and prevents consequent congestion (the arch enemy) in chronic disease.  The myometrium, like living ligatures, control the blood supply of the uterus.      Visceral drainage initiates and maintains peristalsis, which controls visceral blood supply.  A stimulus - whether it be an icicle, red-hot iron, electricity, massage, exercise - is what the flaccid muscles require to maintain peristalsis, which controls secretion and absorption.  The endometrium flooded with excessive secretion (leucorrhea) rapidly assumes its normal secretion by stimulating the myometrium (by douche, massage, etc.).
    A - Visceral Drainage by Fluids. - The best diuretic is water.  It is the greatest eliminant.  A man of one hundred and fifty pounds should produce daily some forty-five ounces of urine.  If we calculate the loss of fluid by the tractus perspiratorius, tractus intestinalis, and tractus respiratorius, it will require about five pints of the ingested fluid to produce daily forty-five ounces of urine.  Many subjects do not drink over three pints of fluid daily, and that is performed chiefly at meal time, not only burdening the tractus intestinalis with the meal, but fluid also.  Large numbers of people drink insufficiently and suffer consequent oliguria.  Such subjects are burdened with waste-laden blood, inflicting irritation and trauma on the nerve periphery.  They are in conflict with their own secretions.  Many women oppose free drinking, from the idea that it creates fat.  Ample quantities of fluid, at regular intervals, is the safety valve of health and capacity for mental or physical labor.  Ample fluids not only flush the sewers of the body, but wash the internal tissues and tissue spaces, relieving waste-laden blood.  The soluble matter and salts are not only dissolved (preventing trauma and infection) and eliminated, but the insoluble matter and salts are flooded from the system, relieving wasteladen blood by such powerful streams of fluid that calculus is not liable to be formed.
    For many years I have diluted the urine, increased its volume (consequently, increased ureteral peristalsis), and clarified it by administering eight ounces of one-half or one-quarter normal salt solution, six times daily.  I have made sodium chloride tablets (twelve-grain, each with flavor).  The patient places on the tongue a half tablet (NaCl), and drinks a glass of water (better hot) before each meal.  This is repeated in the middle of the forenoon (ten A. M.), middle of the afternoon (three P. M.), and at bedtime (nine P. M.). The patient thus drinks three pints of (one-quarter to one-half) normal salt solution daily.  This practically renders the urine normal, and acts as ample prophylaxis against the formation of urinary, hepatic, pancreatic, fecal calculus, and sewers the body of waste material. The formation of a calculus can not occur when ample fluid bathes the glandular exit canals.  In deficient fluid, crystals form calculus with facility.  The maximum concentrated solution of urine, bile, or pancreatic juice, tends to crystalize with vastly more facility than dilute urine, bile, and pancreatic juice.  In "Visceral Drainage" single crystals, on first formation, are rapidly floated with facility when ample fluids are present; while in small quantities of fluid, with weak stream, the crystals tend to lodge, accumulate, and form calculus.  Oliguria is a splendid base for calculus formation.
If parenchymatous nephritis exists, the NaCl should not be administered, as it excessively stimulates the renal parenchymatous cells.  In such cases administer the water only.
    For over ten years I have been using sodium chloride tablets, more or less, in my practice.  During that time some practical clinical views have been gained, and repeated so frequently that they have become established, I think, beyond the shadow of a doubt. The following propositions have been repeatedly demonstrated so many hundreds of times during the last ten years in our clinics and surgical operations, that I shall consider them established until otherwise disproven:

    1.  Sodium chloride (in one-half to one-quarter normal physiological salt solution) is a powerful stimulant to the renal epithelium (tractus urinarius).
    2.  Sodium chloride should not be administered in parenchymatous nephritis (not even in food), as it exacerbates and irritates the diseased, inflamed parenchymatous cells.
    3.  Sodium chloride (in one-half to one-quarter normal physiologic salt solution) is a vigorous stimulant to the epithelium of the tractus intestinalis, inducing fluid to flow into the lumen, stimulating peristalsis and softening the feces.
    4.  Sodium chloride increases absorption, secretion and peristalsis of the tractus intestinalis.  It is an excellent remedy to quench thirst after peritonotomy, by copious gradual rectal irrigations (allowing a pint in forty-five minutes to flow over the sigmoid and rectal mucosa).
    5.  The administration of eight ounces of one-half to one-quarter normal physiologic salt solution (better hot), every two hours, for six times daily, will increase the quantity and clarify the urine, eliminate its color, making it appear almost like spring water in three to five days.  The feces will be softened, increase, in volume, inciting peristalsis.
    6.  Sodium chloride is a vigorously active stimulant to glandular epithelium (as that of the tractus urinarius, tractus intestinalis, tractus cutis, salivary, hepatic and pancreatic glands).
    7.  The effect of the one-half to one-quarter normal physiological salt solution (six times daily) on the tractus urinarius is to increase the quantity and clarify the urine.

    B - Visceral Drainage by Foods. - To drain the viscera by proper foods may sound paradoxical, but the four grand functions of the tractus intestinalis - peristalsis, absorption, sensation and secretion - are maintained, practically, by food alone.  The appropriate food produces the appropriate degree of peristalsis, and the quantity of intestinal secretions, which is absolutely essential for visceral drainage-and to prevent constipation.  The food that will induce proper peristalsis, stimulate sensation, absorption and secretion, is that which leaves a large residue to stimulate the distal bowel, enteron and colon, such as cereals, oils, and vegetables.  Peristalsis is necessary for secretion, for peristalsis massages the secretary glands in the tractus intestinalis, enhancing secretion, e. g., the rational treatment of excessive uric acid in the urine consists of administering food that contains elements to produce basic combinations with uric acid, forming urates (usually sodium), which are freely soluble.  This will diminish the free uric acid in. the urine.  Excessive uric acid in the urine is an error in metabolism.  The question of diet to determine is: (a) What kind of food causes the calculus-producing material in the urine? (b) What kind of food influences the solubility of the calculus-producing material in the urine?
    1.  The meat-eater is the individual with the maximum quantity of free uric acid in the urine.  Flesh is rich in uric acid.  Hence, in excess of uric acid in the urine, flesh (meat, fish and fowl, are all about equal in power to produce uric acid) should be practically excluded, because it increases free uric acid in the urine.  Flesh eaters have uric acid stone. vegetarians have phosphate, oxalate stone.
Generally, the subject who suffers from uric acid is a generous liver, liberally consuming meat and highly-seasoned foods, indolent and sedentary persons, and alcoholic indulgers.  Thirty-three per cent of uric acid is nitrogen.  Uric acid is derived from the nuclei that form a constituent of all cell nuclei, and which are taken in the body as a food.  Beef bouillon may be cell administered, because the extract matters in it will scarcely increase the uric acid.  A general meat diet largely increases the free uric acid in the urine.
    2.  The food should contain matters rich in sodium, potassium and ammonium, which will combine as bases with uric acid, producing alkaline urates, which are perfectly soluble in the urine.  These typic foods are the vegetables, which not only render the necessary alkalies to reduce and transform the free uric acid into resulting soluble urates, but leave an ample residue to cause active intestinal peristalsis, aiding in the evacuation through the digestive tract.  Hence, the patient should consume large, ample quantities of cabbage, cauliflower, beans, peas, radishes, turnips, and spinach in order that the sodium, potassium, and ammonium existing in the vegetables may combine, as bases, with free uric acid in the urine, producing soluble urates, thus diminishing free uric-acid.  A vegetable diet diminishes the free uric acid in the urine thirty-five per cent less than a meat diet.  Again, the administration of eggs and milk (lactoalbumin) limits the production of uric acid.  The most rational advice is to order the subject to live on a mixed diet, consuming the most of that kind of food which lessens the uric acid in the urine - vegetables.
    If the appropriate food is so valuable in "visceral drainage treatment" of the typical uric acid subject, the appropriate food selected for subjects of biliary and pancreatic calculus will be relatively as useful.  The foods that make soluble basic salts with secretions should be selected.  Besides, the selection of appropriate food is frequently amply sufficient to drain the intestinal tract to prevent constipation.  It is true, foods alone are not a complete substitute for fluids, but vast aid in visceral drainage may be accomplished by administering food containing considerable indigestible matter, so that a large fecal residue, saturated with fluid, will stimulate the intestines, especially the colon, to continuous vigorous activity, maintaining the maximum action of the four grand functions-peristalsis, absorption, sensation and secretion.  For many years I have treated subjects with excess of uric acid in the urine by administering an alkaline laxative tablet in fluid.  The tablet is composed of: Cascara sagrada, one-fortieth of a grain; NaHCO2 one grain; socotrine aloes, one-third grain; KHCO3, one-third grain; MgSO4, two grains.  The tablet is used as follows: One-sixth to one tablet (or more, as required, to move the bowels once daily) is placed on the tongue before meals, and followed by eight ounces of water (better hot).  At ten A. M., three P. M., and bedtime, one-sixth to one tablet is placed on the tongue, and followed by a glassful of fluid.  In the combined treatment the sodium chloride tablet and alkaline tablet are both placed on the tongue together.  This method of treatment furnishes alkaline bases (sodium and potassium and ammonium) to combine with the free uric acid in the urine, producing perfectly soluble alkaline urates, and materially diminishing the free uric acid.  Besides, the alkaline laxative tablet increases the peristalsis, absorption, sensation and secretion of the intestinal tract, aiding evacuation.  I have termed the sodium chloride and the alkaline laxative method the "visceral drainage treatment." The alkaline and sodium chloride tablets take the place of the so-called mineral waters.  Our internes have discovered that on entering the hospital the patient's urine presents numerous crystals under the microscope.  However, after following the "visceral drainage treatment" for a few days crystals can not again be found.  The hope of removing a formed localized ureteral, or other, calculus, lies in securing vigorous ureteral or other duct peristalsis with a powerful ureteral or other duct stream, aided by systematic massage over the psoas muscle and per vaginam.  Subjects afflicted with excess of uric acid in the urine, or other form of calculus, need not make extended sojourns to watering places, nor waste their time at mineral springs, nor tarry to drink the hissing Sprudel, for they can be treated successfully in a cottage, or in a palace.  The treatment of a uric acid or other calculus consists, therefore, in the regulation of food and water.  It is dietetic.  The control, relief and prophylaxis of uric acid diathesis or tendency to other calculus formation, is a lifelong process.  When the uric acid or other calculus has passed spontaneously the patient does not end his treatment, but should pursue a constant systematic method of drinking ample fluids at regular intervals, and eat food which contains bases to combine with the free uric acid or other compounds producing soluble urates or other soluble compounds.
    I continue this treatment for weeks, months, and the results are remarkably successful.  The urine becomes clarified, like spring water, and increased in quantity.  The tractus intestinalis becomes freely evacuated regularly daily.  The blood is relieved of waste-laden and irritating material.  The tractus cutis eliminates freely, and the skin becomes normal.  The appetite increases, the sleep becomes improved, the feelings become hopeful.  The sewers of the body are well drained and flushed.
    Chronic constipation is compensatory, for during this condition a greater portion of the food ingested undergoes digestion and absorption than in the normal individual, and consequently the fecal residue is more limited.  By reason of the fecal residue there is less material, and a less favorable medium for the development of bacteria, in consequence of which less irritating products occur, on which the stimulus to the required peristalsis, more or less, depends.  The varying pressure of the abdominal walls on the viscera modifies the viscera circulation in quantity and rapidity.  The visceral vessels, especially the abdominal, constitute a kind of hemogenous reservoir for surplus of blood, by which general blood pressure may be regulated among viscera.  The dilatation of abdominal visceral vessels may be so great that cerebral anemia may advance to a state of syncope, collapse, or shock.  We may yet learn to apply Bier's congestion, or blood controlling methods, to cure constipation by practicing on the sphincters.  Abdominal visceral circulation must not only be controlled for maximum digestion (which is normal absorption, secretion, sensation and peristalsis of the enteron), but also for maximum colon peristalsis, which is required for normal evacuation.  We know that mental or physical excitement at meals modifies digestion (which means modification of circulation).  Dilatation of the blood vessels in the splanchnic area lowers the blood pressure, increases rate, rhythm and force of pulse.  Maximum circulation in abdominal organs is conducive to maximum absorption, secretion, sensation and peristalsis.  Pathologic increase of circulation in the abdominal viscera leads to corresponding activity of unction.  This lends a clue to treat constipation.  Increased secretion of the glands of the tractus intestinalis, in consequence of nervous influence, is well known (which refers to circulation).
    Visceral congestion (chronic) leads to relaxation of visceral supports.  Interruption of circulation (anemia) leads to visceral spasm, colic.  Spasm of the muscle of the digestive apparatus produces colic.  There can be slight doubt, clinically, that spasmodic (anemic) constipation occurs - e. g., lead or (anemic) colic.  In the practice of medicine the vascular area governed by the splanchnics will be more utilized in therapeutics.  For example, the headaches, dizziness, faintness, syncope, vertigo, which appear and disappear suddenly without sufficient time for autointoxication, infections, are likely to produce circulatory changes in the splanchnic and producing cerebral anemia.  So, also, cold bands and feet, aching pains in limbs, neuralgic pains in various bodily regions, may be due to excessive tendency of blood to the splanchnic area.  Irritation of the nerves of the splanchnic vessels are transmitted to distant regions, leading to spasms (anemia, ischemia) of vessels, and pain, cramps in muscles.  This may explain the frequent colic, cramps, of neurotic subjects.
    Circulatory disturbances in the tractus intestinalis should not be mistaken for: (a) Mechanical irritation from coarse food, (b) chemical irritation from ingested irritants (as acids, spices, meats), (c) pathologic physiology, as excessive, deficient or disproportionate secretion and consequent fermentation (microbic).  The dilatation of the splancbnic vessels are physiologically opposed to the dilatation of the peripheral vessels, and since the splanchnic vessels are controlled by a nervous mechanism, it may be hoped that a definite therapeutic remedy will appear that will contract, or dilate, these visceral vessels.  Since physiologic antagonism exists between the splanchnics and peripheral vessels, agents which dilate the splanchnics contract the peripheral vessels, and vice versa.  The dilatation of the anal sphincter dilates and flushes the peripheral capillaries with it, contracts the splanchnic vessels.  The peripheral vessels may be dilated by mechanical means, as massage, hypertrophy, a hot and cold water chemical irritation, as mustard, turpentine.
    Normal evacuations of the tractus intestinalis require an ample stream of fresh blood irrigating the intestinal tract, which is accomplished by administering food with indigestible remnants.
    The tendency of the blood stream to any other visceral tract than the intestinal, lessens the peristalsis, absorption, sensation and secretion, favoring constipation.
    In pubertas, menstruation, gestation or chronic genital inflammation, the circulation tends toward the genitals, robbing the tractus intestinalis of blood, inducing constipation.
    In the puerperium the patient should exercise, employ gymnastics, massage the abdominal muscles, ingest foods which have a residue, and limit the enforced rest to a week, in order to restore muscular action and visceral circulation, especially the intestinal.
    Chronic inflammation, tumor, irritation on any one visceral tract, tends to unbalance the normal circulation in all other visceral tracts - inducing constipation - hence to improve constipation, remove the disease or disturbance in other visceral tracts.
    Any defective segment of the tractus intestinalis (gastrium, enteron, colon) should be repaired, and any defective function (peristalsis, secretion, sensation and absorption) should be restored.
    A subject of one hundred and fifty pounds requires five pints of fluid daily to produce ample visceral circulation (to supply the physiologic demands of the tractus urinarius, tractus cutis, tractus respiratorius, tractus intestinalis).
    Vegetables and graham bread (which should contain the flour, shorts and bran) leave ample residue to stimulate the tractus intestinalis, inviting a vigorous circulation.
    Rectal injections and colonic irrigation should not be employed frequently, as the rectum may lose its sensitiveness, becoming so blunted in sensibility that it will forget to act when fecal matter is present.  Clysters of oil are excellent remedies to soften fecal masses.
    Persistent use of galvanic and faradic electricity produces favorable effects on constipation, the electricity energizes the abdominal walls and intestinal muscles. However, I can not report such favorable results as those of C. V. Wild, in his excellent essay, "Die Verheutung und Behandlung der Chronischen Verstopfung bei Frauen und Madchen."
    Constipation, if pursued by both patient and physician, with favorable will and energy, is practically a curable disease.