Constipation is an exceedingly frequent symptom under many and diverse circumstances. Pathologically, we account for it in several ways: 1, torpor of the muscular coat of the intestinal canal; 2, deficiency of secretion in the glands of the bowels and in the liver; 3, imperfect innervation of the abdominal organs; 4, mechanical obstruction, as by a foreign body, intussusception, strangulated hernia, cancerous or other tumor, stricture of the rectum, etc. Dyspeptic persons are ordinarily constipated. So are almost all patients at the beginning of attacks of measles, scarlet fever, small-pox, and other acute febrile maladies. Typhoid fever is scarcely an exception to this; although the bowels in that affection become loose after a few days, they seldom are so at the very beginning of the attack. Sea-sickness is commonly accompanied by total or nearly total inaction of the bowels, the secretion of the intestinal glands being almost null, often for many days together. Torpor of the brain is sometimes attended by marked constipation. The latter may be a contributing cause of the former, as in certain severe cases of scarlet fever, in which threatening coma may be relieved by active purgation. We must not, however, occupy space here by attempting to enumerate the many conditions under which constipation may present itself as a symptom.
Almost as various are the associations of the opposite state of the bowels, diarrhoea. Excessive or abnormally frequent discharges from the bowels may be either fecal, bilious, mucous, membranous, purulent, bloody, fatty, or watery, and they may occur with or without pain and straining (tenesmus).
If, with frequent disposition to pass something, only small quantities of bloody mucus escape, with pain and bearing down, we recognize dysentery. When, instead, a large quantity of colorless fluid, with or without floating flakes (rice-water), comes from the bowels at short intervals, with vomiting of the same sort of material, we suspect epidemic cholera, and must inquire for corroborative or corrective indications in reference to that suspicion. Very bad cases of cholera morbus also may, at a late stage, present this symptom. So may exceptional cases of pernicious malarial fever. The diarrhoea of typhoid fever exhibits usually liquid stools of a brownish color (gutter-water passages). Occasionally, hemorrhage from the bowels adds to the danger of this fever, as well as to that of malarial remittent fever. In phthisis pulmonalis, at a late stage, colliquative diarrhoea, like colliquative perspirations, shows the breaking up of the system by excessive waste. Very foul, offensive discharges from the bowels may always be understood as showing that in the alimentary canal, whether originating there or in the blood, morbid changes have been going on. The indication is to promote the elimination of such material as soon and as thoroughly as possible.
Clayey stools show absence or deficiency of bile in the intestines, whether from its non-secretion by the liver or from obstruction to its entrance by a gall-stone in the common gall-duct. Green stools are not uncommon in sick children. The cause of the color has been much disputed. Probably it depends chiefly on a modification of the bile-pigment, with some admixture of altered blood. When mercurials have been taken sulphide of mercury may give a green color to the discharges.
Blood, nearly or quite unmixed, coming from the bowels, may have its origin in internal hemorrhoids, intestinal ulceration, cancer of the rectum, intussusception, rupture of an aneurism, typhoid or yellow fever, or vicarious menstruation.
Pus is discharged per anum in cases of dysenteric or other ulceration of the bowel; also when an abscess occurring in any part of the abdomen (most frequently hepatic) opens into the intestine. Pseudo-membranous discharges, shreds or other fragments of fibrinous material, appear sometimes in what may be called diphtheritic dysentery. Tubular casts are occasionally seen (diarrhoea tubularis), which, however, are most likely to consist of thickened and accumulated mucus. Fatty discharges from the bowels are rare. Authors report observation of them in cases of disease of the liver or pancreas, as well as in phthisis, typhoid fever, diabetes mellitus, cholera, and tubercular enteritis of children.
Lientery is the term applied when imperfectly changed food appears in the stools. It shows, of course, great deficiency in the process of digestion.
Urination affords symptoms often of extreme consequence in disease. Suppression of urine is one of the most alarming of signs; an approximation to it only is likely to be met with in cholera, a late stage of scarlet fever, typhus or typhoid fever, in acute yellow atrophy of the liver, and in advanced kidney disease. Careful examination of the abdomen, by inspection, palpation, and percussion, as well as by inquiry of attendants, is needful in all cases of fever or other disorders with delirium or stupor, to ascertain the presence or absence of retention of urine. Dysuria—i.e. difficult urination, strangury—may have several causes. Cantharides, absorbed from a blister, may produce it temporarily. The more continuous states which cause it are—stricture of the urethra, enlargement of the prostate gland, and calculus in the bladder. In stricture, when the patient can pass water, it is apt to be in a twisted stream. Dribbling often occurs when the prostate is enlarged. When a stone is present the stream may flow naturally for a time and then suddenly cease from obstruction at the outlet of the bladder. Enuresis, incontinence of urine, is often very troublesome in children; its diagnosis presents no difficulty.
Diabetes properly means simply excessive flow of urine. It may be attended by no change in the secretion except dilution of its solids (diabetes insipidus), as in certain nervous cases or after very large imbibition of fluids. More serious is diabetes mellitus, in which large amounts of sugar are found in the urine.
Variations in the quantity and in the composition and solid ingredients of the urine, as ascertained by aid of chemical analysis and the microscope, will be fully considered in other portions in this work.