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It is customary to discuss in our journals the graver forms of disease, because they attract the ever-vigilant attention of physicians who are liable to be called upon to attend serious and dangerous cases. On the other hand, the more tedious forms of disease, the attendance and care of which form the greater part of our practice, are less often made the subject of observations. Constipation, ordinarily so called, is one of these rather neglected subjects. There was a time when all the energies of practice were concentrated upon the intestinal canal. Diseases were to be purged away; inflammation was to be combated only by removing offending "juices." That depletion of the period has happily passed away, and the change from a severe to a milder form of treatment is owing to the influences of homoeopathy, as even its opponents now concede.

Although older generations of doctors have given place to younger ones, and a harsher practice to a milder one, patients are the same as they always were, often demanding active measures where even heroically inclined physicians have just scruples.

Constipation, though less of a bugbear among people than catarrh is at present, is still a troublesome ghost that haunts the minds of invalids. Many who present themselves for treatment begin their narrative by asserting that sluggish bowels are the cause of all their discomfort. "Just give us something," they say, "that will insure a free, easy, and copious discharge every day, and all will be well." Inquiry generally shows that such persons have tried many remedies of their own, or, more commonly, have followed the advice of the ever-ready "friend," whom



every patient has, and who unhesitatingly risks his reputation as a prescriber of medicines, when he would be much more cautious and reticent in his actual calling.

It is a prevalent notion that constipation is the cause of many morbid conditions, and if we take a too hasty glance at our patients, we might easily fall into that error. More careful examination of such cases very often reveals numerous symptoms which point to the opposite, namely, that instead of being the cause, it is the consequence of a more deeply seated pathological state than a mere affection of the mucous membrane of the bowels. The symptom of costiveness and constipation is generally the first to be mentioned by the patient; but on looking further into the case we will generally find many other symptoms which are not to be overlooked. Prominent among them is often a state of mental anxiety concerning health, which is not only stated in words, but plainly evinced by the serious expression of the face, the intense watchfulness of the eye, the subdued and even mournful tone of the voice in which the history of suffering is related. It then appears that such invalids also suffer from pains, which give rise to alarm, sometimes impressively emphasized, sometimes cautiously admitted, in proportion to the timidity or moral fortitude of the patient. Physical examination in such cases reveals no organic disorder; the pains are capricious, changeable as to locality and time, often taking the form of intercostal or facial neuralgia; at all events, adding seriously to the patient's solicitude. Appetite and sleep may be disturbed, but not necessarily so, and, as a usual thing, such patients are actively and intensely occupied by their calling.

Such invalids worry much about their food; they either fast unnecessarily, or indulge in a variety of articles supposed to be “loosening," and sedulously avoid everything which, in common phrase, is called "binding," thus falling from error into error, which often plunges them into a state of great mental and physical misery from which it is difficult to extricate them.

The watchfulness with which homoeopathists are accustomed to regard their cases has long ago led them to insist on the importance of mental symptoms. In the instance just described, these very phenomena point to a disturbance of the nervous system, especially of that portion known as the sympathetic, which

governs the functions of animal life, respiration, circulation, and prominently that of digestion; and here, again, the peristaltic motion of the intestines, which, in such cases of constipation, seems to proceed slowly and feebly. In the absence of such function the secretions of the intestinal tract are diminished, as shown by the hard, dry, and infrequent fecal discharges. The pains alluded to are the result of reflex nerve-action, resulting from arrested intestinal function; the mind becoming gradually conscious of the disturbance in the nerve centres, takes alarm, and gives expression to its fears, attributing the anomalous condition to the absence or irregularity of the function of defecation.

In this case, constipation (or its lighter form, costiveness) is the result of some disturbance of the nerve centres. The causes which lie back of this are sometimes known, at other times very obscure. They are often hereditary, or "constitutional," derived from parents of whom one or both were subject to diseases of the nervous system. In other cases, the disposition to constipation from nervous causes has been acquired by certain habits; onanism is a prolific source. Great mental care, and a certain one-sided and over-solicitous application to business, in individuals without other mental resources, and parsimonious disinclination to mental recreation, are not infrequently a basis for the development of very chronic costiveness and constipation. If this be a correct observation, the inference is well founded, that this symptom requires a kind of mental or nervous predisposition.

When not the result of hereditary or constitutional predisposition or temperament, the irregular or intermittent action of the bowels has been acquired. Such cases are much more tractable than the former variety, though they also may have become chronic, and consequently obstinate. Sedentary habits are justly considered as a frequent cause. A normal digestion requires muscular exertion, that is, muscular contractions, which propel the blood to and from the heart. Absence of such exercise of the abdominal muscles renders them feeble, and deprives the abdominal viscera of that wholesome pressure which they must have to insure a free and active circulation in the vascular system of the abdominal cavity. In this connection, I may point to the enormous pressure the intestines of a healthy, muscular laborer are made to endure, for instance, in plying the crow-bar,

or lifting a hod of bricks. In such subjects constipation will not occur; but it does very often in the continued absence of exercise of the abdominal muscles.

Catarrhal and other disturbances of the intestinal mucous membrane are, no doubt, frequent sources of costive habit. Niemeyer does not hesitate to classify costiveness among catarrhal affections of the bowels. There is much reason for it, as it may be likened to the dry, stuffed condition of the nose in certain forms of coryza. There is no doubt that such a condition is often acquired by persons not particularly predisposed by constitution and temperament, but rather through unavoidable necessity, occupation, etc. Those of sedentary habits are naturally costive, especially if the ill effects of too much bodily repose are not counteracted by methodical exercise. Persons who are obliged to earn their living without sufficient physical exertion, as tailors, type-setters, bookkeepers, seamstresses, etc., naturally become enfeebled, and acquire a proportionate aversion to muscular exertion. This is only one instance of many out of which grow other disadvantages to health.

Many slight indispositions, accompanied by costiveness, are quickly aggravated. A person enjoying tolerable health in spite of insufficient air, exercise, and food, thinks little of a certain degree of bodily discomfort, such as headache and sluggishness; but as soon as a day or two are passed without defecation, a kind of terror alarms the mind, mingled with much of a superstitious nature about stoppage, cancer, and fecal matter poisoning the brain. Something must be done at once; a laxative or even a copious purge is recommended and used. The result is a moral relief to the mind; the conscience is unburdened, together with the bowels, but the actual bodily relief is not exactly in accordance with the patient's fond hopes. The brief period of lightness of body and mind is soon replaced by a sense of physical and mental debility, more discomfort and more inclination to resort to purges, enemas, etc., until this form of self-treatment is formed into a habit lasting for years, while the patient becomes a perfect slave to the idea of "keeping his bowels open." This will henceforth be the chief duty of his existence, and a fixed idea, hallucination.

Among the favorite remedies resorted to, the enema is often

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that which holds out longest, as medicinal purges are soon left off as too distressing. Hence, we find persons who have not had a fecal discharge for years without an enema, and, indeed, they would have to wait long for such an act without an injection, because the bowel becomes habituated and dependent on it, and refuses to act without it.

Many chronic cases of this kind present themselves, having become obstinate and almost incurable under the notion of the necessity of keeping the bowels open, regardless of other dietetic and hygienic means. Had a little patience and common-sense guided such persons on the first day on which the bowels did not happen to move satisfactorily, years of mental anguish might have been saved them. I say mental anguish, because such a patient has no bodily aches or pains of great importance, measuring the happiness or misery of a day entirely by the freedom or torpidity of his rectum. In a certain sense ludicrous, they are objects of pity in the main.

(To be continued.)



THE annual volume of reports from the several departments of Saint Bartholomew's Hospital in London, for 1878, estimates the number of prescriptions to in- and out-patients during the year at 190,000. Dr. Moore, who reports concerning the casual patients, describes the method of going through with the crowd which gathers at the hospital each forenoon. He finds that for his share of the work, his average time for each patient is one minute and seventeen seconds. For such hasty prescribing he draws some comfort from the fact that a large part of them come for trivial ails, and he thinks that a ticket for the inexpensive bottle of infusion of quassia with tincture of iron, which is given to great numbers of them, meets their needs pretty well, in view of the debilitating influences about them.

Sir James Paget, in 1874, called attention to the considerable number of cases that had come within his knowledge, in which eczema, or other chronic eruptions on the nipple or areola, had

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