CONSTIPATION.
The most potent cause is the habit of disregarding the call of nature to evacuate the contents of the bowel or postponing the response till a more convenient season.
A correct knowledge of the normal function of the bowel is essential before any progress can be made as regards either prevention or cure. In the great majority of healthy subjects the faecal matter collects and remains about the sigmoid flexure of the colon, and does not descend into the rectum till just before the act of defecation (see the author's " Practice of Medicine," vol. i., p. 236). Its descent in health occurs usually once a day and generally after the morning meal, probably synchronising with the commencement of breakfast digestion after the stomach's long night rest. As soon as the rectum receives the contents of the colon its sensitive walls become stimulated, and the resulting reflex is the call of nature above referred to. If attention to this be postponed the delicate nerve mechanism becomes deranged and the natural sensitiveness of the rectum blunted, because instead of being empty at all times save during the few moments before defecation it remains constantly full of fatcal matter whose tendency is to become drier and harder. After a time the natural alarum clock arm ion 01 the rectum ceases, evacuation then being only accom plished by the contraction of the colon driving the hardened contents of the toneless rectum in front of the Inure recent feculent contents accum ulated about the sigmoid, this action being assisted by the voluntary expulsive efforts of the abdominal and other muscles. The main object of treatment should never in chronic cases be to effect purgation, but to restore the normal daily rhythm of the lower end of the colon and rectum. There is little, howes er„ to be gained by the oft-given advice that the patient should go to the water-closet and strain or bear down from day to day till his efforts are rewarded by a painless operation; the result too often is the formation of piles, fissures or prolapse.
The ordinary water-closet seat is ill constructed; each attempt at bear ing down drives the pelvis tighter into the circular aperture of the seat, the bevelled sides of time opening also acting as an inclined plane, and the result is that the skin and mucous membrane around the anus become stretched to such an extent that cracks and fissures are formed, and the writer has satisfied himself that the brittle and unhealthy state of the integument observed in this region is owing to this stretching, which is often the starting-point of prurigo and eczematous distress. The modern
fashion, originating in the sense of comfort and ease, should be corrected by the substitution of an aperture of different shape, and very much larger.
Until the bowel begins to show signs of responding at the fixed hour enemata may be tried. A cold-water enema of about a tumblerful, injected whilst in the standing posture, so as only to reach the lower part of the rectum, is the best method of starting the intestinal tube to contract. Glycerin, in doses of a teaspoonful or less, injected with a syringe made for the purpose, acts powerfully by stimulating the membrane, but its popular professional reputation as a remedy for constipation rests alto gether upon a misconception of its advantages. b'y its powerful stimula tion of the coats of the rectum (partly through its hygroscopic property), it ultimately blunts the sensibility of the rectal nerve filaments to smaller stimuli, and if solely relied upon the end will be worse than the beginning. Its value seems to be clearly like that of most purgative remedies; it is of use in tiding over constipation till other means have time to act.
In the form of a suppository Glycerin affords a convenient method of overcoming temporary constipation. Often within five minutes a copious and painless motion may be experienced after its introduction, and in constipation arising during fevers and long illnesses its action is very satisfactory. In hxmorrhoidal conditions and in cases of anal fissure, however, its use sometimes may bring on a very acute attack of pain and tenesmus. The writer prefers the use of a piece of common brown Soap shaped roughly into a cone with a penknife and inserted within the internal sphincter.