People who are afflicted by habitual constipation suffer from headache, loss of appetite, foul breath, and many signs of indigestion. The term "constipation" is a relative one. One daily evacuation of the bowels may be regarded as normal; but some people only feel well when they have two or three movements a day. Others feel well who are moved every second or third day, and do not feel well if they are moved oftener. The former usually have a healthy appetite and take ordinary foods to satisfy it; those who are moved two or three times a day probably take somewhat more food than they need, or the food itself is of such a character that it leaves a large residue. Many constipated persons have a poor appetite or the food consumed by them leaves very little residue. Nevertheless, it is observed that persons living on precisely the same kind of food, and eating about the same quantity, differ from each other in regard to their evacuations. This is probably due to the fact that in one person the mucous membrane is more sensitive to the presence of food, and in the other it is sluggish, having little sensibility and not readily provoked to peristaltic action.

The consequences of the retention of faeces are equally varied. In one person there may be a general unfitness for the duties and pleasures of life; in another the presence of faeces in the flexures of the colon produces considerable discomfort and puts the patient in a disagreeable state of mind ; another may develop "food fever". The chronic and durable effects of constipation are more serious; chronic intestinal catarrh, mucous and membranous colitis, and other affections of the alimentary canal, are the local effects; all those diseases which have been mentioned as the results of intestinal indigestion are numbered in the general consequences of constipation.

The causes of constipation are many: Habitual neglect of the daily call of Nature; atony of the muscles of the bowels, particularly of the colon and rectum, common in chlorotic girls, dyspeptics, and persons of sedentary occupation; the character of the food - milk diet, meat diet, - absence of those materials which stimulate intestinal movement, such as vegetables and fruit, and a deficiency of liquids; painful affections in the neighbourhood of the rectum and anus, piles, fissure, chronic metritis, salpingitis, painful affections of the ovaries, bladder, etc.; pathological affections of the bowels : (1) spasmodic stricture, arising from hypersensitiveness of the mucous membrane, excoriations by rough and hard substances in the food, ulcers; (2) organic stricture due to malignant disease or the healing of ulcers - dysenteric, syphilitic, typhoid, or tuberculous; (3) compression of the bowel by abdominal tumours, traction by such tumours forming a kink in the tube; (4) kinks caused by bands and adhesions; (5) torsion or twisting of the bowels, internal strangulation, intussusception; impaction of foreign bodies. The distinctly surgical cases will be left out of this discussion, except in so far as the condition may be influenced by the food or ordinary methods of treatment.

Constipation is one of the consequences of human progress and civilization. In a state of nature men eat their food after very little preparation. But civilized people wish it to be not only well cooked but carefully prepared, in order that it may please the aesthetic sense, which is one of the marks of our progress. Bread was originally made from grain reduced to a coarse powder in a quern or primitive mill, and very little, if any, of the bran was removed. To-day we have it ground in a steel mill, and every particle of bran is removed to make fine flour and produce a white loaf. The influence of mankind on the development of his food is shown in many of the products of the garden. Most of our vegetables and fruits have been evolved from small and comparatively unpalatable substances, containing a considerable amount of indigestible fibre, which could not fail to act as a stimulus to peristaltic action in the bowels. The cabbage which weighs several pounds has been developed from a colewort weighing only a few ounces; and the cauliflower from a colewort flower only weighing a few grains; celery from an acrid and unpleasant plant growing wild in our fields; potatoes from a small and bitter root in South America; apples from the wild crab of our woods; and plums from the sour sloe. The great changes produced in our food by art and cultivation, the absence of coarse fibre, the reduction in the amount of organic or vegetable acids and salts, are largely responsible for the predisposition to atonic constipation in human beings living in civilized society. In the treatment of constipation of the ordinary type, therefore, we must get back to Nature. The patient must consume all those articles of food which contain the greatest amount of cellulose (fibre), vegetable acids, salts, and other substances which stimulate the bowels to action. He should eschew fine white bread and take in its place wholemeal or brown bread. Oatmeal, especially coarse meal, such as " Miller's pride," should constantly form part of one meal a day, preferably breakfast. It may be taken as porridge, Yorkshire parkin, oatmeal biscuits, or oatmeal pudding. Pearl-barley pudding is also useful. Rye bread or cakes and buckwheat cakes are equally useful. Dried peas and beans leave a large residue, and should frequently be consumed. Bread and cakes containing fruit (currants or raisins), treacle, and ginger have a slightly aperient effect.

All vegetables may be consumed, especially those usually considered fibrous and indigestible: cabbage, kale, savoy, brussels sprouts, cauliflower, spinach, onions, leeks, carrots, turnips, swedes, Jerusalem artichokes, skirret, sweet potatoes, kidney beans, broad beans, green peas, etc. Also salads containing lettuce, endive, dandelion, sorrel, radishes, green onions, beetroot, tomato, mustard and cress, watercress, and other green vegetables, will assist in the cure. Fruit may be taken in abundance, raw and cooked, especially apples, pears, plums, prunes, figs, dates, gooseberries, cranberries, strawberries, raspberries, currants, grapes, oranges, bananas, etc. Puddings made with a pastry crust, such as boiled apple puddings, rhubarb puddings, or " dumplings" containing any of the foregoing fruits may be taken. Jam, marmalade, syrups, sugar, honey, are laxative.

It should not be imagined that the diet is to be absolutely "vegetarian"; that is unnecessary. The patient may have a moderate amount of any meat, fish, or bird. Fat meat, butter, and cream are useful. Boiled eggs are constipating to many people; those fried in fat, buttered eggs, and omelettes are not usually constipating.

The patient is not compelled by this complaint to give up any kind of food, unless it causes indigestion, biliousness, or other unpleasant symptom. But it will be understood that if a sufficiency of the above-named foods is taken, the patient will have no necessity for those which leave little residue. If milk puddings, blancmange, and custard are eaten, some fruit or vegetable must form a part of the meal. The same remark applies to concentrated foods like potted meat, fish, or fowl; foie gras and caviare may be useful, if they do not cause biliousness. Nuts are usually taboo; but it is unnecessary to exclude them when an abundance of fruit or vegetables is consumed. Jellies are useless to such patients; but agar-agar (sold as Chinese or Japanese gelatine) is a useful remedy for constipation, very little of it being digested.

The "grape cure" may be employed. This consists in the consumption of several pounds of grapes daily, beginning with about two pounds and increasing the quantity to six or more pounds a day. The treatment can be carried out at home; but many people prefer to go to the Tyrol and other Continental countries where there are proper establishments for this treatment.

The patient must take plenty of fluids. Water may be taken cold or hot to the extent of three or four pints a day, unless there is some contra-indication. Special table waters may be used, such as Bourne, Malvern, Perrier, Apollinaris, Salutaris, Puralis; or the patient may go to Leamington, Bath, Harrogate, etc., to "drink the waters". Fruit juices will assist in the cure, e.g. grape-juice (Vin de vie), "' rough' " cider, rhubarb juice, and the juice of elderberries, currants, plums or other fruit may be used to flavour water. With regard to alcohol, the less the patient takes the better; red wines should be avoided; a little white wine (Chablis, Moselle, Sauterne) may be allowed. Ale and stout are not constipating. The morning cup of coffee is laxative; tea, especially strong tea, is rather binding.

Stricture of the Bowels, causing constipation, whether of a spasmodic (spastic constipation) or pathological character, requires very different treatment. In these conditions we have to avoid irritating the mucous membrane or leaving a large residue of food. The diet must be soft, bland, and somewhat concentrated. Animal foods should form a considerable share of each repast. Scraped meat, raw meat, meat juice, potted meat, tongue or chicken are useful. Ordinary meat should be deprived of every particle of skin and gristle. Fruits should be deprived of skin and seeds. Green vegetables should only be given after they have been reduced to a puree or consomme. Sago, rice, tapioca, and arrowroot puddings are suitable. Jellies of all kinds are good. Junket, custard, eggs, sour-milk, kefir, cream, cream cheese, fine white bread, and potato (mashed and creamed) will do no harm, perhaps; but brown bread, oatmeal, turnips, carrots, swedes, salad, and ordinary vegetables (except as a puree) must be forbidden.

In certain cases an operation is necessary for the removal of constipation. Colectomy is an operation for the removal of a part of the colon for chronic constipation and malignant or fibrous stricture of the bowel. Resection of part of the small or large intestines may have to be done for stricture, gangrene, strangulation, intussusception, or malignant growth. Colotomy either through the loin or the anterior wall of the abdomen may have to be performed to make an artificial anus. After these operations the food should be much reduced in bulk for about a week. It may consist of milk, milk and barley-water with sugar, milk pudding (rice, sago, etc.), custard, junket, jelly, a little fish, scraped meat or a poached egg. The amount of milk should not be large, not more than two pints a day. Nutrient enemata may be given when the operation has been upon the small intestines; in such cases also thirst may be relieved by enemata of warm water. When the operation has been on the colon no enemata should be given. After colotomy the diet must be of a similar character, but much milk cannot be allowed because it tends to the formation of scybala ; oatmeal, vegetables and fruit, on the other hand, may soon form a liberal portion of the diet.