36 Sterk, "Ueber den schudlichen einfluss der chronischen Stuhlverhatten auf den Gesamur organismus," Wien. med. Presse, xxii., 1881, p. 330 et seq.
DIAGNOSIS.—The diagnosis of constipation is not difficult except in hysterical women, who select this as one of their subjects of deception. Primary must be distinguished from secondary constipation, the last being a symptom of some general or local disease. The history of the case and the predominating symptoms will be guides to a decision, but constipation should be regarded as a symptom until it is proved to be otherwise. The tendency is to look upon it and to treat it as a distinct malady; important organic changes elsewhere may thus be overlooked. Simple habitual constipation may be mistaken for constipation due to lesions in the wall of the intestine or to closure from the external pressure of tumors.
Slowly-developed symptoms of obstruction may come from polypoid growths or benign tumors in the rectum, colon, cæcum, duodenum, and ileum. They are usually found in the rectum. The diagnosis can only be made when the growth is in the rectum or when the tumor is expelled from the bowel. Cancerous obstruction is accompanied by cachectic changes, by the presence of an abdominal or rectal tumor, the passage of blood and mucus, and violent rectal or abdominal pain. Primary cancer in the small intestine appears in the form of lymphoma; it readily ulcerates, and rather widens than narrows the channel of the bowel.37
37 Wilks and Moxon, Path. Anat., Philada., 1875, p. 417.
Stricture of the bowel is most commonly found low down in the rectum or sigmoid flexure, within reach of the finger or exploring bougie. If high up, it can only be diagnosed by exclusion and by its slow progression from bad to worse. Syphilis or dysentery has nearly always preceded the development of stricture.
Tumors in the abdomen or pelvis compress the colon, and while they are small they may be overlooked; sooner or later they grow so as to be recognized.
The presence of gall-stones as obstructions may not be detected until they are passed. The previous occurrence of attacks of hepatic colic, followed by jaundice, gives rise to the suspicion that gall-stones are in the intestine if they have been carefully looked for in the stool but never found.38 Enteroliths give no indication by which they could be known to be in the bowel.
38 In a case seen by the author three separate attacks of typhlitis occurred in a young woman suffering from chronic constipation. After the last attack she passed from the bowel several dark, irregularly-shaped concretions. The largest of these was a gall-stone covered with fecal matter. Since this time—two years ago—there has been no recurrence of inflammation and the constipation is much better.
All forms of constipation from organic modification of the walls grow worse and have no remissions; some rapidly progress toward a fatal termination. Simple constipation is subject to improvement and relapses due to the character of the food, climate, exercise, etc. The etiology is an important guide.
Stercoral tumors may be known by their position and character as ascertained by physical examinations and by their history. They are found in the iliac, lumbar, or hypochondric regions, and sometimes in other parts of the abdomen. The most common seat is in the sigmoid flexure and descending colon. They are nodulated, movable, painless, can be made to change shape or are indented by pressure, and have a doughy feel. Exploration of the rectum, by detecting impaction, will make the diagnosis clear when the obstruction is low down. The distension of the abdomen above the point of obstruction is limited at first to the region of the colon; but if the colon is much dilated with gas or is displaced, the enlargement becomes more central and more general. On percussion the sound is of a dull tympanitic quality, and never absolutely dull even in cases of great fecal accumulation.39