In many cases constipation does not induce any subjective symptoms whatever. Ordinarily, however, continued constipation gives rise to sensations of slight pressure, fulness and tension in the abdomen; and borborygmi may at times molest the patient. Occasionally intense colicky pains are experienced. These are due to an increased effort of the intestines to rid themselves of the accumulated fecal matter by violent contractions. The abdomen is often symmetrically distended, rarely asymmetrically, namely, in partial atony of the bowels.

1 Carl Ruedi: "On Indications and Contraindications of High Altitude in Phthisis." The Climatologist, July, 1892.

In patients with thin abdominal walls, a more or less filled state of some portions of the intestine, especially of the colon, may be perceived by inspection and palpation. The appetite is often diminished and in some instances complete anorexia exists. Other gastric symptoms - belching, nausea, pyrosis, feeling of pressure after meals, and bad taste in the mouth - may be present. That all these symptoms are due to the constipation and not to a separate lesion in the stomach, is proven by the fact that thoy all disappear as soon as efficient evacuation of the bowels has taken place.

Besides these gastric symptoms the following derangements may be present: congestion of the head, dizziness, headaches, sleeplessness, a despondent feeling, palpitation of the heart, tachycardia, irregularity of the pulse. The latter symptoms have been considered by many writers to be due to auto-intoxication from the intestinal tract. According to the experiments of Bouchard, 1 however, this does not seem to be true, for this investigator has shown that intoxication within the intestinal tract takes place when there is a retention of fluid fecal matter, but not when the faeces are solid, for in this condition no absorption of the fecal matter takes place.

1 Bouchard: Loc. cit.

Constipation which has lasted for a long time, as a rule, terminates by a spontaneous evacuation of ordinarily very hard masses of fecal matter. The latter often appears in the form of balls which may be covered with a thin layer of mucus. In some instances the constipation terminates in an attack of diarrhoea. In these cases the diarrhoea has been caused by an acute hyperemia and inflammation of the intestinal mucosa due to the hardened fecal matter, the latter becoming liquefied through increased intestinal peristalsis and secretion. In other instances no spontaneous evacuation takes place and it becomes necessary to make use of different cathartic remedies in order to produce a movement of the bowels.

Retention of fecal matter may cause not only a slight transient catarrhal condition of the bowels as just referred to, but may, although rarely, effect more pronounced anatomical lesions, as formation of ulcers (stercoral ulcers), local peritonitis, and even perforation of the gut with fatal issue.

One of the serious symptoms which may result from continued constipation is fecal colic. The latter begins with sudden violent pain of a colicky nature in the abdomen. In weakened persons fainting spells may occur. The abdomen is usually greatly bloated and tender on pressure. Passing of wind (flatus) gives temporary relief, but. the pains soon reappear and subside only after an efficient evacuation. Fecal colic is mostly observed in cases of obstinate constipation, although it may occur in patients with daily evacuations of the bowels, but in these insufficient fecal passages must be presupposed. In fact, hardened balls of fecal matter can be discovered in such cases on palpation of the abdomen.

These conditions are not always of a mild character.

As a rule cathartic remedies are efficient. In some cases, however, the latter produce energetic intestinal peristalsis and violent pains, but fail to secure a copious movement. Under these circumstances the patient may after a while sink into a state of collapse and be seized with a paroxysm of vomiting. The clinical picture now resembles very closely that of ileus. High rectal irrigations or injections of oil into the bowel ordinarily yet produce the desired effect and the patient quickly recuperates. In rare cases, however, especially in very old and cachectic persons, these means also remain fruitless. Total paralysis of the intestine now takes place and the patients are then in a most critical condition.

A frequent complication of constipation is the formation of fecal tumors. They are found most frequently in the caecum, rectum, and at the colic flexures. These masses may cause a dislocation of the colon; thus, such a tumor may be felt just above the symphysis and may belong to the transverse colon which has been dragged down to that region. Fecal tumors are as a rule easily recognizable. They are not of a very firm consistency, have a rosary-like configuration, are movable, and undergo a change in shape upon pressure. They may be of large size. Thus Levi1 found the rectal pouch of a patient suffering for nine years with constipation filled with a fecal mass weighing four pounds. Still larger fecal concretions have been found by Lemazurier.2 These large masses necessarily dilate the colon.

Habershon described cases in which the dilated colon measured twelve to fifteen inches in circumference, and stated that some of the normal sacculations of the colon may become distended to such a degree that they appear as true diverticula. In the latter fecal accumulations may occur which remain undisturbed by the further passage of the intestinal contents. These stagnant fecal masses often produce inflammatory processes which may lead to a destruction of the intestinal coats down to the peritoneum The colon occasionally is distended not only in width but also in length. The latter circumstance explains the abnormal position of the bowel often present in these cases.

1 Levi: Gazette med., 1839.

2 Lemazurier: Arch. gen. de med., vol. i.

Among the local symptoms which constipation produces hemorrhoids play an important part. They are treated in a special chapter.

A host of nervous symptoms may develop in consequence of constipation in people who are apparently not nervously inclined. Thus constipation lasting several days may produce slight cerebral symptoms, namely, a sensation of pressure, weight and dulness in the head, sometimes headaches and vertigo. The dependence of these symptoms upon constipation is proved by the fact that after a full evacuation of the bowels they all suddenly disappear, but again return after another period of constipation. We have as yet no positive explanation of the causation of these symptoms. Some authors assume them to be of a reflex origin.

Leube 1 described several cases of intestinal vertigo in which the dizziness was due to pressure existing in the lower end of the bowels, the vertigo appearing only in consequence of irritation of the intestinal walls by fecal matter or a large amount of gas, or by the examining finger. Leube concluded that pressure upon the hemorrhoidal plexuses of the sympathetic nerve produces the sensation of vertigo in are-flex way.

1 Leube: "Ueber Darnischwindel. " Deutsches Arch. f. klin. Medi-cin. Bd. 36, 1885.

Senator 1 tried to explain the above symptoms as due to the absorption of poisonous gases within the intestine, such as sulphuretted hydrogen, and Nothnagel assumed that ptomains may be absorbed and thus cause an autointoxication. But neither theory seems to hold good; for sulphuretted hydrogen gas exists in too small quantities to produce any marked symptoms, and the fecal ptomains can scarcely be absorbed from dried-up fecal matter.

As mentioned above, real brain diseases, hypochondria and melancholia, are never due to constipation as such. There is, however, hardly any doubt that in nervously inclined individuals obstinate constipation may be a contributing factor in the further development of some psychoses, especially melancholia.

Fecal fever, which has played a great part in the works of old writers, appears to be due in most instances not to an accumulation of fecal matter but rather to some complicating condition, an inflammatory process, a stercoral ulcer, a local peritonitis, etc. In infants and children, however, who much more readily develop fever, the latter may be due to accumulation of fecal matter alone. Some of the English writers have referred to chlorosis as due to habitual constipation, and Clark has treated chlorosis with cathartics. But this view has not been generally accepted and the dependence of chlorosis upon constipation is far from being proved.