When constipation is due to hypertrophy of Houston's valves, Valvoline is indicated and may be accomplished with the clips made for that purpose.

Constipation, constipation and fecal impaction are in many instances due to the same cause and only represent different degrees of intestinal incompetency, so that fecal impaction and constipation are subject later to the general treatment and investigation as applied to constipation.

Enter-spasm (spastic constipation) is probably the symptom of an existing mucous colitis, more common in a mild degree than is accredited. The treatment should be along that line and efforts made to control the catarrh inflammation which may involve the entire digestive tract. Olive oil and castor oil to regulate the bowels and occasionally belladonna to control the spasm in the intestine, combined with tonics, should be the general treatment of these cases.

As much of the intestinal activity is due to chemical stimulation produced by the digestion and decomposition of food, vegetables are of much more value than meats. Fats and their derivatives, glycerin, fatty acids and soaps, are powerful stimulants. So that in an attempt to remedy a deficient amount of digestive residue necessary to stimulate the normal intestinal peristalsis, the diet is of great importance, as the bolus of undigested material or chemical stimulants are nieces-chary to excite peristalsis. Organic acids, produced in the intestine by the fermentation of the carbohydrates contained in vegetable foods, stimulate peristalsis. Cellulose, of which vegetables consist largely, is also a potent mechanical stimulant of peristalsis, and passes through the intestinal canal without undergoing absorption or decomposition, thus serves this purpose. Fecal matter which accumulates in the colon in small quantities, the result of abnormal assimilation and digestion, in some instances will not produce effective stimulation to peristalsis, and auto-intoxication may follow from the extreme delay in the intestinal canal.

Recent experimental investigations have proved that the cellulose contained in different vegetable matter is not acted upon by either the gastric or intestinal digestive ferments and does not undergo absorption or decomposition. Schmidt and Seville Wood have brought the subject practically and forcibly to the attention of the medical profession by their excellent work in this direction. Schmidt suggests the use of agar-agar, and both recommend the use of paraffin. In Germany, bread made from wood shavings has been advocated for this purpose. Agar-agar is slightly affected by bacteria, but since it is composed largely of hem-cellulose it may be readily substituted instead of a large vegetable diet. Agar-agar may be administered in the ordinary dose of one teaspoonful 111 mashed potatoes or stewed apples. This dose may be increased, if necessary, to half an ounce which should be divided between the different meals. The combination of cascara with agar-agar is sold under the name of regulation Hertz relates an apparent toxemia due to the administration of agar-agar for the relief of constipation and attributed the toxic effects to the bacterial growth in the agar-agar which forms an excellent culture medium. Liquid paraffin is so disagreeable to the taste that a few drops of some aromatic oil should be mixed with the dose to be taken. The ordinary dose is from one to six drachma a day.

Strychnine acts in a general way upon the peripheral and central nervous system and is particularly indicated in those forms of constipation which are dependent upon a depression of the central and peripheral nervous system, it increases the tone of the muscular coats, probably by a stimulation of Bernbach’s plexus, causing a stimulating diet or purgatives to be more effective.

Atropine decreases excessive peripheral nerve excitability and tends to a regular peristalsis in cases of mucous colitis or enter-spasm Its value is limited to such cases and it proves of little use in other forms of constipation which are due to different causes. The pain accompanying enter-spasm due to lead poisoning, in which there is an irritation of the vague, is relieved by its effect upon the nerve ends. In these cases atropine does not assist the evacuation of the bowel so that a purgative should be administered at the same time.

Vegetable purgatives, such as aloes, senna, cascara, and rhubarb, owe their purgative action to an irritation of the motor-nerves from the anthracite compounds which they contain. Aloes take from ten to twelve hours to act upon the bowels and are considered one of the slowest of the vegetable purgatives. In my experience aloes are a positive irritant to the rectum, and the same may be said of chlorophyll, senna, and the resinous bearing purgatives in general. Their use should be avoided if possible when hemorrhoids, fissure, proctorial or any irritation of the rectum, due to other forms of disease, exists.

Cascara gradate is probably the best drug for constipation when it is necessary to continue medication. It should be combined with strychnine and when used for a long period should be alternately given with aloes, senna, or chlorophyll This drug seemingly irritates the colon and rectum less than any of the other vegetable purgatives excepting rhubarb. Rhubarb, owing to its astringent after effects, should not be used for the relief of constipation.

Castor oil, which is split into glycerin and reciprocal acid by the pancreatic juice, is not indicated in the treatment of constipation, owing to its after constipating effect, excepting when the condition is due to hypertrophy catarrh colitis, senile constipation and spastic constipation.

Saline Purgatives. The commonly accepted theory of the action of saline purgatives has been proven by the experiments of Hertz to be erroneous. He has found by X-ray investigations that a saline purgative given before a meal reached the cecum, in combination with bismuth hydrochloride, in four hours, but the subject had emptied the bowel two and a half hours earlier, supposedly from the purgative. That the purgative had not traveled faster than the bismuth was proven by observations on two patients with fistula at the end of the ilium. The greater part of the purgative was found in the stool the next day. The only explanation possible was that the salt had been absorbed from the smaller intestine and acted from the blood on the euro-muscular apparatus of the colon, producing increased activity of the motor and secretory mechanism. Saline purgatives do not enter the duodenum until they have become isotonic with the body fluids by dilution with the secretion of the gastric mucous membrane. (Hertz.) Absorption then takes place from the duodenum into the blood. So that the administration of saline purgatives should be recommended before meals, while the stomach is empty, to facilitate its rapid absorption. The analysis of urinary excretions show that about one-half the quantity of saline purgatives are passed off by the kidneys. Salines empty the colon without interfering with digestion in the small intestine or stimulating muscular activity.

The relative values of vegetable foods, as compiled in the following table by Robert Hutchinson and quoted by Hertz, is well worthy of study in the treatment of constipation, when medication has not afforded the desired results. In combination with the vegetable purgatives very excellent results can sometimes be gotten if the bowels are forced to a habitual evacuation after breakfast by injecting about eight ounces of cold water. The water stimulates an immediate movement of the lower bowel which may be followed after a few days' treatment with a regular movement. This cold water treatment is necessary each day for a period of not less than two weeks but may, if needed, be carried on for a longer time at intervals of every other day. In looking over the table of relative cellulose values which the vegetables and fruits contain, spinach is of much importance in the treatment of constipation. The presence of sugar and organic acids which fruits contain should also be added as a necessary complement in diet form of treatment.