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Diseases Attended with Constipation

bowels, pain, action, patient, accompanied, progress, lead and spasmodic

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§ 1. us assume that the other indications of the general state of health do not point to any febrile disorder. The tongue indeed may be coated, and the appetite bad ; but thirst is not urgent, the skin has no unnatural heat, and the pulse is quiet : any specialty of the urine must be considered separately. In this simple form the patient merely seeks a remedy for con stipation of the bowels. W e inquire into the condition of the stomach, and most commonly find some indication of dyspepsia; and it may be a question which of the two is primary : we seek also for evidence of biliary derangement, knowing this secretion to be of paramount importance in aiding the expulsion of the feces.

In such a case we derive much information from its history : the progress of the disorder has been gradual; the patient has had costive bowels for years, probably, before he has consulted any one on the subject ; he has taken aperients, and then again has tried to do without. His habits next serve to point out the nature of the evil : he has perhaps led a sedentary or irregular life ; and in addition to this, his food may have been either luxu rious and over-stimulant, inducing plethora; • or it may have been the reverse, and he has become anaemia. Patients, too, as they consider themselves competent to manage their own bowels, have something else to complain of when they seek advice—headache, occasionAl colic, or congestion of the lower abdominal viscera, resulting in haemorrhoids, or in uterine hemorrhage or leucor rhcea.

The two principal causes of constipation seem to be deficient secretion and want of peristaltic action : plethora rather points to the former, general anaemia or atony to the latter. But in the end, as accumulation of feculent matter proceeds, the muscular fibres are necessarily stretched, and become incapable of contract ing efficiently; the fluid portion is absorbed, and masses of hard impacted feces remain in the bowels. Just as in other involun tary muscles, the constant result of over-tension and imperfect power, is spasmodic and irregular action—colic, of which a very important variety has been mentioned as the effect of lead poison ing: the symptom is the same, whether there be lead in the system or not; but the blue line indicating its presence ought in such circumstances always to be sought for (see Chap. VI., Div. I., § 3). A very important result of this imperfect action is, that the feces get impacted and indurated in the colon and rectum : this is fol lowed by thin watery secretions, which find their way past the hardened mass, and lead the patient to imagine that he is suffering from diarrhoea, and to use astringents, which increase the disorder.

The abdomen becomes tumid ; dull percussion sound on the left side and over the,brim of the pelvis indicates the existence of accu mulation ; and when purgatives fail to act, it may be suspected that there is some physical impediment to its egress, and the case puts on the characters of obstruction.

§ 2. Enteritis.—This disease is only distinguished from other forms of obstruction by the presence of fever ; it is accompanied by inaction of the bowels after the administration of purgative medicine. pain of every variety of intensity, and vomiting, which is apt to become feculent or stercoraceous.

A broad line of distinction can be traced between cases com mencing suddenly without previous constipation, and those in which the attack is a mere aggravation of a pre-existing state. Colic has been mentioned as one of the results of habitual cos tiveness ; but it is still more common when constipation is caused by some error in diet, or by some hardened mass unexpectedly interrupting the progress of the excrementitious matters, when, the bowels had been acting regularly : it occurs as a spasmodic and grinding or tvristing pain, which is not at first accompanied by tenderness, but, on the contrary, is relieved by pressure. This circumstance serves at once to distinguish it from that of peri toneal inflammation : it is more liable to be confounded with the pain caused by the passage of a gall-stone (see Chap. X.XIX., Div. I., § 5). By judicious treatment, the peristaltic action per haps once more returns to regularity, the bowels are evacuated, and the patient is restored to health. But if the remedies fail, the pain is soon accompanied by tenderness, the spasmodic action ceases, and is followed by paralysis, in consequence of inflamma tion ; febrile symptoms are developed, medicines are rejected by vomiting, and no action of the bowel takes place ; the pain is more permanent, its exacerbations and intermissions are less marked ; in short, enteritis has supervened in consequence of the obstruction, and there is more or less of its accompanying peri tonitis : in the further progress of the disease, the abdomen be comes tense and tympanitic, the pulse small and thready, vomiting, which is partly stercoraceous, is followed by hiccup, and collapse, and death.

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