Constipation, especially in its Relations to the Diseases peculiar to Women. BY ANDREW F. CURRIER, M. D. REPRINTED FROM THE Neto York fHetacal .Journal for February 11, 1893. Reprinted from the Few York Medical Journal, for February If 1898. CONSTIPATION, ESPECIALLY IN ITS RELATIONS TO THE DISEASES PECULIAR TO WOMEN* By ANDREW F. CURRIER, M. D. That so large a portion of the human race is afflicted with constipation is a fact of great interest from which im- portant deductions can be drawn. Assuming, as we fairly may without argument, that the intestinal canal is not in- tended as a reservoir for the storage of excrementitious mat- ter, ordinary clinical experience informs us that of the great multitude of individuals in whom occur this unnatural storage and the other elements which constitute constipa- tion, the condition is the expression of disease with some, while with others it is an expression of neglect—partly due to ignorance and partly to indolence. This leads naturally to the observation that the far-reaching influence and sig- nificance of constipation are not appreciated by a very con- siderable portion of the community. For this situation the medical profession is largely to blame, for it includes the instructors in hygiene to individuals and to families which * Read before the Section in General Medicine of the New York Academy of Medicine, October, 1892. Copyright, 1893, by D. Appleton and Company. 2 CONSTIPATION. make up the community. This arraignment must extend to many of our clinical teachers, and especially to that system of teaching in which diseases are classified and con- formed to rigid rules as if pathology were one of the exact sciences. Thus the student goes forth to his practical work with his head crammed with theories and notions to which he vainly endeavors to conform the phenomena which he witnesses. This is no disparagement to the scientific grouping of symptoms, but rather an appeal that induction, and not deduction, is the proper method of con- sidering the morbid states of the body. In human beings it may fairly be said that constipation is omnipresent. We witness it in the convulsions of the new-born infant with an inactive and overloaded bowel, and in the coma sometimes terminating in death in the aged from the same cause, and in the intervening period it presents phenomena of every degree of intensity and va- riety. It is the result of habits and occupations, climate and diet; it is caused by conditions of exactly opposite character, by fasting or full eating, by watching or sleep- ing, by exercise or indolence, in those who are anaemic and those who are plethoric, the idle and the industrious, the temperate and the dissipated. 1 have seen two p*ople who sat at the same table, did the same amount of work, in fact, experienced conditions which were practically identical, and who were in good physical condition when brought to this similarity of experience, develop diarrhma in the one case and constipation in the other. I am aware that this is a common observation, and it is mentioned simply as an illustration of the infinite variety of causes which result in constipation. It is often said that women are more frequently constipated then men, and that this is to be explained by their indoor and sedentary life ; but this is an unsatisfactory explanation, for many men who lead an indoor life are CONSTIPATION. 3 constipated, and many women are constipated whose lives are not sedentary, but very active. Here, again, we are confronted with the protean character which distinguishes constipation. The reciprocal influence of constipation and pelvic disease in wx>men must be apparent to every one who is brought in contact with the morbid conditions which are grouped under the latter comprehensive term ; indeed, it has seemed to me that the structure and func- tions of the pelvic organs in the female have more to do with the cause and continuance of constipation than any other factor. A study of the histories of one hundred con- secutive cases in the records of my private practice showed that in sixty-five there was manifest and annoying consti- pation. It must be remembered, moreover, that the term constipation, with women more than with men, is a relative one, and that if the statements of all of the one hundred women in question had been based upon the same physio- logical and psychological standard, more than sixty-five would have admitted the existence of constipation. But if we limit our argument to the statements of these individu- als as they were given, these one hundred women may be considered an average representative of women who suffer with pelvic disease, for all of them consulted me with refer- ence to such disease, either complicated or uncomplicated with disease of other parts of the body, and the diagnosis included almost every recognized form of disease or lesion of the pelvic organs.* * The sixty-five cases were distributed as follows: Atresia vaginae cum cardiopatlna, 1; anaemia, 3; anteflexio uteri, 1; carcinoma uteri, 2 ; cystitis (from hairpin in bladder), 1; endometritis, 11; gonorrhoea cum cystitide et peritonitide, 1; hsemorrhoidae, 2; hyperplasia uteri et pro- lapsus vaginae, 1; myoma uteri, 6; neurasthenia, 1; obesitas et innutritio uteri, 1; parametritis, 2; pyosalpinx, 11; ruptura cerv. et perin., 1; retroflexio aut retroversio uteri, 6; sarcoma uteri, 1; septicaemia post abort., 2 ; sterilitas, 2 ; syphilis, 1 ; tumor ovarii, 3 ; utero-gestatio, 5. 4 CONSTIPATION. The fact that nearly two thirds of these women were constipated to an annoying extent is a proof, to my mind at least, of the correctness of the statement which was made—of the very great importance of the symptom con- stipation in its relation to pelvic disease in women. It may seem presumptuous to offer a definition of con- stipation, but it is not improper when we take into consid eration the fact that there is much latitude of opinion upon this matter, simple even to transparency though it may ap- pear at first thought. We can always progress more fa- vorably and satisfactorily upon any subject when our eyes are fixed upon it from a common standpoint. I shall at- tempt no refinements of statement, hut would consider con- stipation as simply that condition in which the intestine fails to readily expel the excrementitious matter which it contains at intervals sufficiently frequent and in a mass of suitable consistence to insure the individual against detri> ment from waste and decomposing material. This definition takes into consideration the injury that may result from hardened faeces, the intoxication which may result from the bacteria of the intestine and their ptomaines, and is in harmony with the fact that the act of defecation is the resultant of mechanical forces generated by the voluntary muscles of the abdomen and the involun- tary muscle of the intestine. This act is dependent to a certain degree upon the exercise of the will; but, on the other hand, the will may be sufficiently strong, while the muscles do not co-ordinate with it, defecation taking place in spite of the inhibition of the will. It may take place without the participation of the will, as in sleep, in paral- ysis of spinal origin, or insufficiency of the sphincter mus- cles. The will may be active and defecation may be at- tempted, but prove a failure from weakness of the abdom- inal muscles, as in women with very fat, relaxed, or pendu CONSTIPATION. 5 lous abdomens, or the muscular force of the intestine may be insufficient to propel the fiecal mass onward, or a me- chanical obstruction outside the intestine may bar the way. Consequently any cause which impairs the activity of the voluntary or involuntary muscles concerned in the act of defecation will tend to produce constipation. Such causes may be removable or unremovable ; they may consist in neglect, in disease within the intestine or without the intes- tine ; they may be mechanical, neurotic, or vascular. Some of them are predisposing and others are inevitable. Trau- matism and neoplasm may play a conspicuous part. In short, when we reflect upon the many ways in which this nicely adjusted mechanism which controls the act of defe- cation may get out of order, we begin to understand why it gets out of order so frequently. CAUSES OF CONSTIPATION. Neglect.—Of all the preventable or removable causes from which constipation in women originates, neglect or indolence is the most common. It is most noticeable in girls and young women; it is less noteworthy in mature women, perhaps because they have learned better, perhaps because it has brought on other evils for which they have sought relief; it is least apparent in the aged. The care- lessness of young girls, especially schoolgirls, in the mat- ter of evacuating the bowels is proverbial, and the resulting constipation is the foundation of so many physical evils that it would be far better for these individuals and for society if their intellectual culture were curtailed, and the time devoted to physical exercise or to any means of activity whereby the evils in question could be anticipated and prevented. Morbid Conditions within the Intestine.—Under ordinary conditions the inclination to evacuate the bowels is caused 6 CONSTIPATION. by the deposit of faecal matter within the rectum, the mu- cous membrane being excited or irritated by its presence. Hence there is reason in the statement which is to be found in the text-books on physiology that the rectum is usually empty. But the sensitiveness of the rectal mucous mem- brane varies greatly in different individuals, and in women it seems to be less acute than in men. In iny experience the rectum of women is rarely free from faecal matter ex- cept after particular preparation, and the insensitiveness which accompanies it has much to do with the constipated habit. Constipation in both sexes is a common occurrence as the result of disease of the intestine above the pelvis, but certain forms of such disease occur much more frequently in women than in men. Peritonitis may serve as an illus- tration which is especially common after abdominal opera- tions and with disease of the pelvic viscera. The paralysis of the bowel and retention of excrementitious matter which characterize it are often the prelude to a fatal issue. Pro- longed retention of faecal matter within the large bowel, even leading to the formation of a large abdominal tumor and complete paralysis of the bowel, is by no means unusual in women. Constipation may also be effectually produced by infiltration of the bowel structure with malignant or syphilitic disease or by polypi in its interior. Morbid Conditions within the Rectum, Medical and Sur- gical.—The causes which are operative in the production of paralysis of the bowel above the pelvis are similarly opera- tive and to a much greater extent on that portion which is within the pelvis. These causes may be considered with reference to the treatment which is usually employed for their relief—that is, from a medical and a surgical standpoint. In the former are to be included the thickenings and new formations of syphilitic origin, the dilatation and muscular weakness accompanying prolonged inattention to the accu- CONSTIPATION. 7 mulation of faecal matter, as in certain cerebral and spinal diseases, congestion and engorgement of the venous system of the rectum associated with menstruation, pregnancy, or obstruction in the portal circulation. From the surgical standpoint causative conditions are to be found in fissures, ulcers, and haemorrhoids, polypi, infil- tration of the tissue with malignant or inflammatory disease, dilatation and weakness due to prolapse of the vagina, or rupture of the perinaeum, or both. Medical Conditions.—Of those conditions in which medi- cal measures are indicated for their relief, syphilitic disease of the rectum is sometimes eminently amenable to such re- lief, but a diagnosis of syphilitic stricture of the rectum in women is not always easily made, and the condition may be treated surgically and ineffectually because of such an error. The constipation which is associated with cerebral disease as effect must be distinguished from constipation which is the cause of such disease. I have seen a case within a few months in which a life was nearly lost through want of such discrimination. Probably the case would have been fatal if the accumulation of faecal matter had not been re- moved. The constipation which accompanies dilatation of the rectum and in which there is functional trouble alone is usually remediable, but the task is a severe one, for the pro- longed and systematic use of medicaments by persons who have carelessly allowed a constipated habit to creep upon them is with difficulty enforced. If constipation is due to spinal lesions, it is, of course, irremediable, excepting in the few cases which are susceptible of surgical treatment. When associated with pregnancy it may be as a new condition re- sulting from vascular engorgement, or pressure due to dis- placement, or it may be merely the intensification of prece- dent constipation. Cases of this character are too often examined and treated with insufficient care, especially in view 8 CONSTIPATION. of the important relations subsisting between open bowels and the parturient and puerperal states. The use of cathar- tics in a thoughtless manner is responsible for the prema- ture termination of pregnancy in any number of cases, and the aid which they render the criminal abortionist is well known. The periodical occurrence of constipation with the men- strual flow is a result of venous congestion, and is remova- ble by medical means. The same may be true if the rectal congestion is associated with an obstructed portal circula- tion. These are all important points but can not now be discussed. Surgical Conditions.—In constipation due to surgical conditions of the rectum the trouble is irremediable in far- advanced malignant disease, especially if it has extended from the uterus. If there is rectal dilatation as an accom- paniment of prolapse of the vagina or rupture of the peri- najum, the indication is clear. The results in such cases are not always satisfactory, especially with very fat women, with those whose muscles are relaxed from many pregnan- cies, and with the aged, in whom the muscular tissue of the intestine and the genital organs has mostly disappeared. Of the other surgical conditions which have been men- tioned in this connection, their removal is usually followed by the removal of the constipation. This statement has been verified many times in the treatment of haemorrhoids, ulcers, fissures, and strictures. Morbid Conditions External to the Rectum.—The dispo- sition of the viscera in the female pelvis is such as to make constipation possible if the normal arrangement is but slightly disturbed. Constipation under such conditions is due primarily to a mechanical obstruction, which, as a rule, will require surgical means of some character for its re- moval. If left to Nature, the result may be a very trying CONSTIPATION. 9 one, though it is by no means the fact that a cure never results spontaneously. Such cases frequently illustrate the marvelous accommodative powers of Nature under adverse circumstances. The rectum is closely united to the uterus for a portion of its course ; consequently, anything which materially disturbs the position or surroundings of the uterus must disturb, to a greater or less degree, the rectum also. This disturbance, if serious enough, must also cause dis- turbance of function, and thus we can rationally explain many of the cases of constipation which attend uterine dis- orders. There are at least two ways in which a mechanical ob- struction external to the rectum may act upon it—(1) as a mass pressing upon a certain portion of it and retarding its contractions or making them irregular, or (2) as an im- bedding mass in which the rectum is more or less firmly fixed and more or less paralyzed. The longer the rectum is subjected to either of these forms of obstruction the more persistent will be the resulting constipation; not only is the muscular coat of the rectum paralyzed, but there is paralysis of sensation in the mucous membrane as well. The accumulation of faecal matter goes on unheeded for considerable periods, and when a sufficient stimulus does occur, which leads to the emptying of the bowel, it is ac- companied with much pain and straining and often with loss of blood. As examples of obstructive conditions of the first kind may be mentioned posterior displacements of the uterus, whether the latter be impregnated or unimpreg- nated, and tumors of the uterus or its appendages. As long as these masses are movable, their obstructive effect may not be of serious importance. A retroflexed uterus, whether gravid or not, may be replaced, and the rectal trouble which it was causing may disappear. But if adhe- sion takes place between the rectum and the overlying mass, 10 CONSTIPATION. an event which usually occurs if the apposition continues sufficiently long, the function of the rectum will be materi- ally disturbed, the condition then merging into that of the second class, in which the rectum is more or less imbedded or surrounded by a mass from which it can not free itself, and in which muscular contraction is restrained or prevent- ed. This condition is often caused by pelvic inflammations with effusions of pus, blood, or serum, and by the effusions of malignant and tubercular disease. Even though the fluid elements of these deposits be absorbed, bands and bridges of adhesion material will remain, and as these contract the rectum is the more tightly bound in their embrace, which, of course, does not tend to the relief of its disturbed func- tion. Consequences of Constipation, Near and Remote, in the Conditions mentioned.—Constipation may therefore exist as cause and as result; it may be due entirely to neglect or to conditions over which the individual has absolutely no con- trol. Tn either case it is interesting to note its consequences, and this may be done by considering the subject in three groups, the first of which shall include those individuals in whom constipation results from inattention, neglect, or any other cause outside the pelvis. In this group the com- plaint arising from the constipation is principally inconven- ience. The second group will include those in whom there has been neglect and also more or less pelvic disease, but with whom the predominant symptom relates to the retained excrementitious matter. In other words, the predominant symptom in this group is sepsis. The third group includes those in whom pelvic disease is so pronounced that constipation would be inevitable whether there had been neglect or not. In this group the predominant symptom is pain. In the mild cases, which are included in the first group, little harm is caused aside from CONSTIPATION. 11 the inconvenience, especially with women who are not very sensitively organized. They may be able to attend to their ordinary occupations without much interruption. Defeca- tion may be painful, the straining and loss of blood may be troublesome, and there will certainly be an absence of that sense of relief which a normal movement of the bowels always gives. The faeces are extruded in hard lumps, their fluid elements having been absorbed during their retention in the bowel. There may be fermentation and decomposi- tion, with the expulsion of foul-smelling gases, but there is very little evidence of septic absorption, and there may be all the outward appearances of good health. In the second group of cases, in which the faecal matter accumulates in the rectum, distending it, and also in the folds of the large bowel, a thorough evacuation is impossible. The pelvic disease in these cases may have preceded the constipation or may have followed as the result of the vas- cular disturbance which has been developed ; or coinci- dently with the constipation there may have existed a dis- placement of the uterus, inflammatory disease of the ap- pendages, relaxation of the vagina and perinasum, or lesions resulting from parturition or the puerperium. The consti- tutional symptoms in these cases are marked, and I do not refer to the symptoms which are characteristic of the severer forms of pelvic disease, but to those which proceed principally from the constipation. There is a marked want of animation in the performance of duties, drowsiness, head- ache, backache, a muddy complexion, a furred tongue, cold extremities, and loss of appetite. Such cases are frequently treated for malaria. Tympanites is troublesome, for de- composition and septic absorption are constantly present. The influence of the bacteria of the large intestine, the de- velopment and distribution of ptomaines, the sapraemia, the development of diarrhoea with vile-smelling passages, are 12 CONSTIPATION. all characteristic of this group. There may also be a clouded mental condition, with gloom and This form of constipation obtains with many insane women, both within and without the hospitals. It is in this group that we meet with faecal tumors, and with these also there may be disturbance of the portal circulation and of the functional activity of the liver. In short, the characteristic sepsis is plainly apparent in the cases which are included in this group. In the third group the cause of the constipation is located essentially in the pelvis, and whatever the previous condition may have been it would seem that constipation was now inevitable. The rectum may be occluded by stricture or polypus, infiltrated with inflammatory or neo- plastic elements, or impinged upon and surrounded by effu- sions or dislocated viscera, and its muscular contractions are either greatly restrained or entirely prevented. Venous congestion is a necessary and continuous consequence of the foregoing conditions. Faecal matter accumulates in the rectum and colon, but it is not impacted, as in the cases in the second group, nor is there stercoral intoxica- tion, as in those. This may be due to the fact that the women of this group are constant sufferers—in fact, pain is the predominating symptom—and hence require constant professional care. The relief, more or less, to the con- stipation is incidental, and it is possible that the drugs which are constantly taken prevent the septic phenomena which are so common with women of the second group. The effect of the pain in these cases is the effect of pain everywhere—a general lowering of the vitality and loss of flesh and strength. Unless they are relieved by surgical measures they become bedridden and easy victims to inter- current disease. In addition to the acute pain in the rec- tum, which is especially acute with every effort at defeca- CONSTIPATION. 13 tion, there is the pain of the monthly period, backache tympanites, indigestion, and many other ills, which, taken together, make the burden of life for them a heavy one. The recommendation of methods of treatment, whether medical or surgical, is to my mind one of the most unsatis- factory features of the work of a teacher or writer. It is so easy for opinions to differ with regard to a given condi- tion, that at the very outset a writer is confronted with a disadvantage in the fact that his meaning may be misap- prehended or his directions misapplied even where there is the utmost candor and good intention in carrying them out. In any case, if the results are not those which were promised and anticipated, there is disappointment and also loss of confidence in the ability and integrity of the writer. Therapeutics, therefore, should deal with principles rather than with rules and formulae, though I can not deny that the latter are sometimes very convenient. If the principle is firmly grasped the application will usually follow. The treatment of constipation, associated as this condi- tion is with a great variety of morbid states, offers a wide latitude for the application of therapeutic Tt must include both medical and surgical measures, and it is unnecessary to say that it is useless to attempt to cure the constipation without removing its cause. The following measures would certainly be indicated in more or fewer cases: (1) cutting operations, (2) electricity, (3) massage, (4) cathartics and aperients, (5) injections and applications in vagina and rectum, (6) tonics. Cutting Operations.—It is becoming more and more recognized that certain diseased conditions of the pelvis which long occupied debatable ground are not amenable to medical treatment, but to surgical only, or to surgical and TREATMENT. 14 CONSTIPATION. medical combined. This has involved a period of education in which many mistakes have been made by those who be- lieved and those who did not believe in radical surgical meas- ures for this portion of the body. But without wandering too far into this bypath, the concrete application of the prop- osition is that when constipation is associated with a rectum which is firmly bound by adhesions or imbedded in exu- date, the chances of relief are not one in a thousand, unless the offending and obstructing matter is removed by a sur- gical operation. When the rectum and vagina are dilated, the perinaeum torn, and the conditions which favor muscu- lar contraction wanting, the constipation will probably go unrelieved until a surgical operation has been performed. Pressure of a displaced uterus upon the rectum may often be relieved by mechanical appliances, but if these fail more radical measures will be indicated in order to allow the rectum to perform its work. The cutting operation may not be all that is necessary to cure the constipation in these cases, but it will often be found an indispensable factor in the treatment. Electricity.—In cases in which there is no serious lesion in the pelvis or elsewhere which causes the constipation, the condition being only functional, and, in particular, due to muscular inactivity, the use of electricity will be rational and effective. A mild faradaic current producing contrac- tions of successive portions of the intestine, or a mild gal- vanic current with the negative electrode in the rectum and the positive upon the abdomen, repeated at sufficiently fre- quent intervals, has been found very useful in many re- corded cases. Massage.—For the same class of cases as the preceding, and also in the relaxed cases, the cases in which both the involuntary and the voluntary muscles concerned in the act of defecation are involved, the judicious use of massage is CONSTIPATION. 15 of great benefit. A skillful rubber is one of the most valu- able assistants which a physician can have in cases of this character. Cathartics and Aperients.—The field occupied by cathar- tics and aperients is a large one, and T can not pretend to do justice to the subject in the brief allusion which will be made to it. The use of the aperient mineral waters, of which so many really valuable ones are now available, will be found very efficient in many of the cases in which the trouble is purely functional, and in others in which they will be required both before and after the performance of surgical operations. A long course of such treatment sys- tematically and patiently carried out will often relieve the most obstinate cases. The list of approved remedies in addition to the mineral waters for persistent and careful use is a long one—too long to be detailed here. One need only mention the preparations in which cascara, aloin, podophyllin, calomel, and senna are the active ingredients. For surgical cases nothing can surpass the usefulness of the salines, which are now so extensively used both before and after operations. Their function in depleting the circula- tion and relieving congestion has saved many lives which would have succumbed to peritonitis or sepsis after the performance of severe abdominal operations. Injections and Applications in the Vagina and Rectum.— The use of glycerin and salines in the vagina and rectum, injections of ox gall, and the oils has played a most useful part both in surgical and medical cases. As they are all free from poisonous properties, they should be used fear- lessly and in large quantities. They are frequently effect- ive when life seems to hang by a thread, and their value in these desperate cases is not yet fully appreciated by the profession at large. Tonics.—There are few cases in which constipation has 16 CONSTIPATION. persisted for any length of time in which tonics with other measures are not proper. Quinine, malt, iron, arsenic, strychnine—all have their appropriate place in this connec- tion. Constipation is certainly debilitating ; it may re- quire this form of treatment or it may require that, and in all cases it should be our aim, to borrow a comparison from comic opera, “to make the punishment fit the crime.” 85 Madison Avenue. REASONS WHY PSiysicians staid Mscrift — FOB — The NewYork Medical Journal, Edited BY FRANK P. FOSTER, M.D., Published by D. APPLETON & C0.} 1, 3, & 5 Bond St. 1. BECAUSE : It ia the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. BECAUSE : Its contributors are among the most learned medi- cal men of this country, 4. BECAUSE: Its “Original Articles” are the results of sci- entific observation and research, and are of infinite practical value to the general practitioner. 5. 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