Constipation, although a symptom rather than a disease, itself becomes a cause of various and often most serious vital disturbances. Every bodily function and every structure may suffer damage through the failure of the body to be relieved of the highly poisonous refuse which it is the duty of the colon to discharge.
The symptoms by which the presence of constipation may be known differ according to the form of constipation which is present.. Although many different forms of constipation have been described, practically all phases of this disorder may be included under three heads, namely:
1. Simple constipation.
2. Cumulative constipation.
3. Latent constipation.
When fecal matters remain in the intestines more than twenty-four hours, constipation exists. Some authorities place the limit at forty-eight hours, while others assert that every individual is a law unto himself, and that a bowel movement once in two or three days is as normal for some persons as a daily or twice-daily movement is for others. The writer feels certain that these authorities are in error. Their conclusions have been drawn from observations made upon unhealthy rather than normal individuals. For reasons stated elsewhere in this work, the writer is fully persuaded that the normal rhythm of the intestine is a movement after each meal, or at least after each full meal. Certainly, when the bowels do not move regularly at least once a day, constipation may be said to exist.
In simple constipation the evacuation of the bowel content is not complete. A normal desire for evacuation occurs when the feces enter the rectum, but normal bowel movements occur only every other day, or perhaps at somewhat longer intervals, or at irregular periods. There is simply a slowing of the rate at which the food moves along the alimentary canal, due to some one or more of the many causes which have been mentioned in the preceding pages; but there is no disturbance of the defeasing mechanism.
Most cases of chronic constipation begin with the simple form. The cause is most commonly a concentrated diet, irregular meals, sedentary habits, or neglect to attend promptly to the "call" for evacuation of the bowels.
In cumulative constipation, which is perhaps the most common form, the difficulty is almost wholly confined to the lower part of the colon. Cumulative constipation is for the most part a disorder of the defecating mechanism. The food and the feces move along the small intestine and the upper part of the large intestine at the proper rate; but after the feces have reached the pelvic colon, they are retained either in the colon itself or in the rectum, instead of being promptly discharged. The special characteristics of cumulative constipation are dry hard stools, loss of the rectal reflex, caused by the retention of fecal matters in the rectum and distension of the rectal walls, and in pronounced cases, complete loss of the "call" for evacuation of the bowels. In cumulative constipation, the difficulty exists in the lower half of the colon, or below the splenic flexure.
In well pronounced cases of cumulative constipation, a considerable quantity of feces will always be found present in the rectum, although in a certain number of cases the accumulation occurs only in the pelvic colon. The latter cases are sometimes the most difficult of relief, because of the existence of obstruction at the pelvi-rectal valve, or of adhesions of the pelvic loop to the floor of the pelvis. Sometimes the pelvic colon has become so large by overstretching that, when filled, it is so heavy that it cannot rise, but becomes impacted in the hollow of the sacrum, folded upon itself and incapable of emptying itself. In such cases, as in most cases of cumulative constipation, bowel movements occur only as the result of pressure from accumulation of feces in the colon, a process which necessarily involves great distension of the colon and resulting injury to its walls, and to the ileocecal valve, which is often rendered by this means wholly incompetent.
When in cases of cumulative constipation the bowels are made to move by violent straining efforts, the rectum is not emptied. A few masses of hard, dry feces, sometimes a single mass covered with mucous, may be extruded, but a thorough emptying of the bowel never occurs. In cases in which the rectum only has lost its sensibility, the sense of weight and pressure often lead the patient to make repeated efforts during the day to relieve the bowels, with the result of securing perhaps each time a small movement. This has been termed "fragmentary constipation" by Boas, the eminent Berlin specialist, but it is only a form of cumulative constipation.
In latent constipation the bowels move regularly, or at least daily. In most cases the patient has no idea that he is suffering from constipation. An examination, however, by means of suitable tests shows that there is delay at one or more points along the food tube. There is no disturbance of the mechanism of defecation. The "call" for bowel movement occurs, and often with inconvenient frequency, and the lower colon is emptied of its contents. There is no accumulation of feces in the rectum, but if a portion of charcoal or carmine is given with a meal, forty-eight hours or even a longer time may elapse before the colored matter makes its appearance, and a longer time before it is all discharged.
The exact point at which the delay occurs may be ascertained by administering a bismuth test meal and watching its progress along the food tube by the aid of a powerful X-ray apparatus. An examination of this sort is highly important in cases of latent constipation, affording the only means by which the real nature and location of the disturbance can be ascertained.
The feces in latent constipation are generally very dark in color, ragged and foul smelling, the result of the advanced putrefaction induced by their long retention.
The reflex contraction of the ileocecal valve produced by the pain of chronic appendicitis and other painful affections of the pelvis and lower abdomen, may be the cause of latent constipation, which, when due to this cause, is sometimes called "reflex" constipation, for the reason that it is generally relieved by measures which lessen the activities of the sympathetic nerve and so relax the ileocecal sphincter. Latent constipation is also very commonly associated with colitis, on account of the spastic condition of the intestine often present in this disease, which may be a consequence as well as a cause of latent constipation.
Incompetency of the ileocecal valve is probably a very frequent cause of latent constipation.
A marked symptom of latent constipation when associated with incompetency of the ileocecal valve is the great amount of intestinal gas from which it is impossible to get entire relief. This is due to the fact that the gas generated in the colon escapes into the small intestine and cannot be wholly expelled because the colon discharged its contents internally, into the small intestine, as well as externally.