A narrowing of the ileo-ctecal valve is the cause of certain cases of obstinate constipation. W. J. Mayo (Annals of Surg., Sept., 1900).
Differential Diagnosis.—Simple reten tion of the fmcal contents of the in testines longer than natural may be considered as sufficient diagnostic evi dence of constipation in an unqualified sense. But as undue retentions of fames are often caused by a variety of mechan ical obstructions, such as strictures, in vaginations, concretions, morbid growths or tumors, and visceral displacements, all these have, by common. consent, been classed as intestinal obstructions, while the words "costiveness" and "constipa tion" are properly made applicable only to such cases as depend upon failure of one or more of the physiological condi tions on which regular intestinal evacu ations depend.
Congenital stricture of the anus or - rectum is a frequent cause of constipa tion, the following being two examples: I. A child, aged 0 months, always sub ject to constipation, became obstinately so after being weaned. Rectal examina tion revealed £1, membranous septum, with sinall central perforation. This em buonic relic had allowed the stools to pass fairly well while suckling continued, but as the hems became more solid, definite symptoms arose. 2. In a baby, a few weeks old, numerous small motions were found to be associated with anal stenosis due to a fold of mucous mem brane which barely allowed a catheter to pass. Congenital rectal stenosis is also said to be due to intra-uterine enteritis, which gives rise to great hypertrophy of the walls of the bowel. Filatow (La MiRl. Infantile, Nov. 15, '97).
Rectal examination is often neglected in infants, and thus the cause may be missed. In healthy infants the little finger can be introduced into the rectum; if this is impossible, some -morbid condi tion is present. Marfan (La Med. In fantile, Oct. 1, '97).
Differential diagnosis involves, first, proof of the absence of mechanical ob structions, and, second, proof that the physiological conditions concerned in natural evacuations are at fault in any given ease. In all cases of intestinal obstruction the pains, distension, and tenderness are uniformly inanifested at some one part of the abdonien or pelvis. If the obstruction is from the pressure of tumors or morbid growths tbese can gen erally be detected by proper physical ex amination of the abdomen.
If from stricture or invagination there will be not only well-marked pains and fullness at some one location, but in strictures, especially, the past history of the patients will show them to have been the sequelm of dysentery, typhoid fever, or some form of primary intestinal ulcer ation. Obstructions by uterine displace
ments or rectal concretions are readily detected by direct examinations through the vagina and rectum.
[A result of chronic constipation often seen, which may not only simulate, but also cause uterine trouble, is enlargement and pouching of the lower third of the rectum. This condition is found very frequently in virgins, and gives the pain in the back, discomfort in standing or walking (more particularly in standing), and the sensations of dragging and full ness, as if the parts would fall. This is due to the distension and varicosity of the vaginal and uterine veins, caused by the formation of a proctocele, press ing the vagina forward. Efforts in def ecation then cause intense pain, press ing the vagina and rectum downward to the pubis and perineum; instead of re lieving the patient, however, the traction on the vagina forces the uterus down ward, and prolapsus or retroversion re sults. In this condition, the correction of the retroversion does not relieve the patient, since the cause is not the retro version, but the rectocele, due to .the constipation. The proper course to pur sue is to cure the constipation, when the reposition of the uterus will cure the symptoms. CHARLES B. KELSEY, Assoc. Ed., Annual, '911 Constipation not caused by mechan ical obstruction may result from im pairment or suspension of the natural peristaltic motion of the intestines, and from paralysis of the nerves of the rectum concerned in the act of defecation, from irregular contractions of the circular fibres of the muscular coat by which regular peristalsis is prevented, from the reversing influence of continuous nausea, from excessive obesity coupled with loss of tone in the abdominal muscles, and from deficient mucous and glandular se cretions, by which the fmces are per mitted to become dry and hard. In all these cases a careful manual examination of the abdomen will detect the presence of frecal accumulations in different parts of the colon and rectum. And their loca tion will vary from day to day, instead of uniformly appearing in the same place, as in cases of obstruction.