Habitual constipation may be divided into three groups: 1. Constipation due to retarded intestinal peristalsis (atony of the bowel). 2. Constipation due to a spasmodic contraction of a certain portion of intestine (enterospasmus, spastic constipation). 3. Constipation depending upon abnormal conditions of other organs.

With regard to the etiology of the first group, namely, constipation due to atony of the bowels, which comprises by far the greater majority of cases, the following may be said: In most instances the constipation is brought on by a repeated neglect of nature's calls. Thus, young girls while in school suppress the desire for defecation out of bashfulness, which gives rise at first to irregularity of the bowels and later on to constipation. The mental state is also responsible to a great extent for the causation of this trouble.

It is not among the working class that constipation is most frequently found, but among the wealthier classes. This shows that the mode of living has much to do with this affection. If we would go a little more into detail and try to analyze cases of chronic constipation, we would learn that the patient had perhaps at first a great deal of worry or of mental strain. At that time his bowels first became sluggish and after a while the affection became more developed. The patient experienced more and more difficulty, began to take drugs, and after a short time was not able to have a movement without medicine.

Often we find that after an acute gastric catarrh there was at first a little diarrhoea, which after a few days changed into constipation. After a short time this would have disappeared of itself, if the patient in his haste to have a movement had not resorted to cathartics, thus upsetting again the normal state of the intestinal tract, in consequence of which chronic constipation developed. Very frequently the patient has some trouble, perhaps a headache, and thinks the stomach is disordered, and begins to live on a one-sided diet, avoids vegetables, butter, fat - all substances which excite the peristaltic action of the bowels - and then constipation arises and assumes a chronic form.

In a limited number of cases the retarded intestinal peristalsis is due to a real muscular weakness of the bowel, the intestinal muscularis being much thinner than normally. Nothnagel observed some cases in which at the autopsy the muscularis of the large bowel measured in thickness 0.12 to 0.25 mm., while normally it ought to be 0.5 to 1 mm. In these cases the muscular development of the entire body was poor. It will therefore be easily seen that such rare conditions cannot be recognized during life.

Informer years the opinion prevailed that chronic constipation gives rise to the developement of numerous nervous affections (neurasthenia, hypochondriasis, hysteria, and even epilepsy and paranoia). Dunin 1 was the first to show that in reality quite the reverse is true, namely, that constipation is the result of many nervous conditions and not their origin, for a treatment directed against the existing neurosis in many instances removes the constipation without the administration of cathartics. Dunin, however, goes too far in ascribing all cases of habitual constipation to a neurosis. There are certainly cases of chronic constipation in which no nervous derangement whatever can be discovered.

Formerly the cause of constipation was presumed to lie in abnormal conditions of the bowels. Thus, peritonitic adhesions of the intestines and congenital malposition of the bowel have been held responsible for chronic constipation. But aside from the fact that these two factors are so rarely found in comparison with the large number of cases of constipation, Leichtenstern 1 proved that an abnormal position of the bowels need not cause constipation as long as the intestinal lumen is not obstructed.

1 Dunin: "Ueber habituelle Stuhlverstopfung, deren Ursachen und Bebandlung. " Berliner Klinik, 1891, Heft 34.

Spasmodic contraction of the bowels or enterospasmm is produced by increased peristaltic action confined to one portion of the bowels. A permanent contraction of a portion of the intestine exists which may affect both the circulatory and the longitudinal muscles. This spastic state may be of variable duration and may involve intestinal segments of different lengths. The contracted portion of the bowel is almost completely occluded, thus creating an obstacle to the onward passage of the intestinal contents.

The enterospasm may involve the entire small intestine. The abdomen then appears contracted in the form of a trough. This condition is met with in spinal meningitis and in other morbid processes involving the pons and the medulla oblongata. Moreover, the same affection occurs in chronic lead poisoning.

Much more frequent than the diffused enterospasm is the localized or circumscribed contraction of the bowel which usually affects a certain portion of the large intestine. Here the abdomen does not show any abnormal appearance on inspection. This condition is frequently met with in nervous people, neurasthenics, hysterical persons, and also in those debilitated by long ailments. Constipation of an obstinate nature, lasting for several days, followed by a painful evacuation of small balls (like the faeces of goats) or leadpencil-shaped fecal matter are the predominant symptoms. Pains in the umbilical region or on the left side of the lower abdomen of a constricting nature and relieved after a very small passage, are also characteristic of this affection.

1 Leichtenstern: "Verengerungen. Verschliessungen und Lageveran-derungen des Darms." von Ziemssen's "Handbuch der speciellen Pa-thologie und Therapie, " Bd. vii., 2te Halfte. Leipzig, 1878.