fainter. This may continue two or three days when the presence of feces in the rectum is brought to our attention through a sensation of fulness and weight.

We can usually diagnosticate chronic constipation if we find with the examining finger a pouching of the rectum above the anus, and small, round masses like sheep dejecta.

The second potent cause of chronic constipation is artificial stimulation of peristalsis by means of laxative medicines, and injections into the bowels. I am sorry to say that the medical profession is responsible for the widespread belief among the laity that a delayed evacuation of the bowels is inimical to health. In the five or six hundred cases of chronic constipation that I have treated, and in numbers of individuals without constipation, I have found that many people have perfect health with only one or two movements of the bowels a week, and I know of one case where the bowels were evacuated but once a month. Most of you know of the case that died in South Dakota this spring where the bowels moved only once a year, and there are many cases recorded in literature where the bowels moved only once every two or three months, and all with good health. On the other hand, I know of cases where the bowels move morning and evening, and many where the bowels move after each meal.

There are many ghosts in the domain of medicine, and there is none that wanders around so persistently, even in the daytime, as the ghost of auto-intoxication. If we were to believe most of our practitioners of medicine we should have to acknowledge that everything, from neurasthenia and insanity to gouty deposits in the big toe, is caused by intestinal toxemia; and this intoxication, mind you, is not from the natural absorption of the food in its passage while in solution and under the best conditions for absorption, but it is from the semisolid mass down in the sigmoid flexure and rectum, from which everything soluble has been extracted, and which has been delayed in evacuation simply, that this dangerous autointoxication comes. Bouchard's investigations of the feces from the rectum failed to show toxine material when extracted and injected into animals, and he says in his book that it stands to reason that everything soluble has been extracted before the feces arrive in the rectum. The point I wish to make is, as Hemmeter says, that there has never been any proof of auto-intoxication from the delayed

evacuation of normal feces. If there is intoxication it must be from the absorption of the soluble matters in the chyme, and especially from the small intestine.

TREATMENT

Remove the cause, i. e., instruct the patient to go to stool every morning whether there be a call or not, and attempt to move the bowels. Let him drink a glass of cold water before breakfast and refrain from all drugs and injections. This is sufficient in the majority of cases. In the bad cases where there is an atony of the stomach and intestines, we can use gymnastics, massage, and electricity. The abdominal massage when administered properly improves the nutrition of the abdominal organs, especially stimulating the large bowel, which is really the only specific organ that should be kneaded. The gymnastics consist in some bending and straightening movements to improve and strengthen the tone of the abdominal muscles particularly, and the electricity is used mainly for this last purpose. The abdominal massage must be taught by a skilled person who understands it, and it should be administered only by physicians and masseurs or masseuses especially skilled.

DISCUSSION

The Chairman: There are certainly some gentlemen here who have had experience in this matter, and most of you are willing to talk about your experience, therefore I would like to hear this paper thoroughly discussed.

Dr. H. A. Tomlinson: I would like to call attention to the effect of perversion of function in the activity of the internal sphincter in the production of constipation. When the feces enter the rectum they give rise to the sensation which calls for the evacuation of its contents. If this sensation is ignored, and the relaxation of the sphincter resisted, a reverse peristalsis is set up, and the contents of the rectum are returned into the sigmoid flexure. Finally, as the result of constant failure in the effort at evacuation, the sensibility of the rectum becomes obtunded, and the feces accumulate and distend it, while the persistent voluntary effort to control the action of the sphincter results in the production of undue irritability, which leads to spasmodic contraction whenever any fecal matter is in the rectum, and in the end this spasm is increased whenever an effort is made to evacuate the contents of the rectum, so that there is a complete reversal of the function of the internal sphincter. I have happened to see a great many cases of this kind of constipation. They are usually associated with some form of disturbance in the nervous system, and they not infrequently occur in women whose occupation or surroundings interfere

with their going regularly to stool. However, the first case of this kind I ever recognized occurred in a case of tuberculosis where there was an ulcer at the anus. The pain accompanying the act of defecation had led the patient to resist the effort at evacuation of the rectum until there was persistent spasm of the internal sphincter. Paralysis of the sphincter by stretching completely cured this case, and has been effective in all of the cases of this kind of constipation which I have since seen. have no doubt but that Dr. Snévé has had a similar experience, although he does not mention it.

I

Dr. C. O. Wright: I was very much interested in the subject of chronic constipation from the fact that the majority of us country physicians have a great deal to do with that class of patients. They come to us with sluggish bowels, and we must resort to some laxative for immediate results; and if we follow out that line we do not think we can do anything better than to relieve the intestines of their contents. However, I think the majority of cases of constipation, especially in women, are brought about by habit. In the majority of places, especially in the country, they have not the facilities they have in the cities, where they have warm closets and other conveniences, and under such circumstances they will naturally neglect nature's call, and if they do this once they will do it again, and as the result of that habit chronic constipation ensues. I most heartily agree with Dr. Snévé in his method of correcting this habit, although many of our patients will say they have tried to overcome this habit, but without result. A very simple thing is known to stimulate the bowels and cause the muscles to respond, and help the patient to overcome the habit. Constipation is not only a bad thing of itself, but it will bring on a nervous condition and give us a double-header. If we overcome constipation we overcome nervousness in these cases.

Dr. Mary S. Whetstone: I have been exceedingly interested in Dr. Snévé's paper, and I rise to emphasize the use of water as a remedy for constipation. The difficulty of carrying out the method advised has been remarked upon. Water is a remedy of value. Everyone can avail himself of its use if so disposed. I have repeatedly advised the free use of water with patients having this ailment, with most gratifying results. One patient thus relieved, exclaimed: "Doctor, tell all your patients having constipation that they may be cured by drinking freely of water. True, not all of this class of patients have been cured; possibly they did not drink as much water as prescribed. One case was extremely obstinate, resisting all remedies; two or three compound cathartic pills had no effect. Finally 1-3 gr. pill of aloes daily affected a permanent cure.

Dr. Haldor Snévé (Essayist): In reference to the point Dr. Tomlinson refers to, I meant to state that the chronic constipation I am speaking about is the idiopathic kind, where there is no connection with any lesion of the bowels or stricture of the rectum or spasm of the sphincters, which are cases that must be corrected surgically. I am speaking simply of the ordinary delayed movement of the bowels.

As to what Dr. Wright mentions: that is, of course, the

same as the multitude of remedies that are invented and have been used in rotation.

Dr. Whetstone brought up the question of the use of hot or cold water. What is there in water that benefits the movement of the bowels? The presence of a great deal of water mechanically gives nature a substance to dissolve things; it makes the contents of the bowels fluid; it makes things softer, As to the use of hot or cold water in the treatment of this condition that is a question of temperature. If you are determined to administer a laxative, give a glass of cold water before breakfast, because cold water produces stimulation, and that accelerates peristalsis. Heat does it also, but to a lesser extent. Heat stimulates peristalsis, but cold is a more intense irritant than heat; therefore, if you want to use an artificial stimulation for peristalsis, prescribe a glass of cold water. Whenever it is necessary to produce an immediate evacuation of the bowels for the purpose of counterirritation or derivation in other diseases we usually resort to some cathartic, and not a laxative. It is not that I decry the use of evacuants for any purpose aside from ordinary torpid bowels; but I do protest against the use of laxatives simply to unload the little accumulation in the lower bowel. We must remember that nature never intended to make use of artificial means for the purpose of evacuating the rectum, because we know that nature has installed a most delicate and efficient apparatus there for that purpose, and it is only, as a rule, bad habit that renders it inefficient. The laity is thoroughly imbued with the idea that if the bowels do not move every day something terrible is going to happen, and the profession weakly submits to the demands for laxatives. One doctor gives cascara, another a. b. s. pills, another some saline, another high irrigation of the bowels, another uses suppositories, and so on ad infinitum ad nauseam. The production of neurasthenia and the multitude of other nervous diseases from the absorption of theoretical toxins in the sigmoid flexure and rectum is ridiculous. If there be absorption, it must occur higher up.

THE VALUE OF SIMPLE METHODS IN THE EXAMINATION OF THE STOMACH

SOREN P. REES, B. S., M. D.

Minneapolis

Based upon a correct diagnosis, the treatment of diseases of the stomach gives better results than that of most other chronic ailments; and without an accurate diagnosis treatment is entirely unsatisfactory. Previous to the introduction of tests for the examination of stomach-contents, treatment was largely empirical. At present the effort to develop and perfect these laboratory aids has

led, in many instances, to chemical and physiological tests so complex as to be far beyond the ordinary practitioner and only within reach of the specialist who has at his command much time, a well equipped laboratory, and trained assistants. This present tendency is well illustrated by the introduction lately of a very elaborate method for estimating the amount of HCl by means of electricity.

Those who are without the facilities of the specialist and who nevertheless honestly attempt to make a diagnosis on which to base treatment, must rely in many cases upon simpler methods, which, while they may not be as accurate as some of the more elaborate, will nevertheless furnish enough evidence to place treatment on a scientific footing. It is to briefly call attention to some of these simpler methods that this paper is written.

The simple method has in itself many advantages. It is within reach of all, saves much time, diminishes chance of error in its development, permits of tests being made in many instances when the longer methods could not be used, and often allows of repeated tests in the same case. This last point is important. Digestion, whether normal or faulty, is such a complex process, and is influenced by so many factors beyond the immediate sphere of the stomach itself, that one finding is often misleading, and repeated tests must be made in order that an accurate average result may be obtained. This is especially true in that large and rapidly increasing group of gastric disturbances commonly designated as nervous dyspepsia. One examination may show entire absence of HC1; and the next day a faint trace, or even a large percentage, may be found.

That chemical and microscopical tests, though only approximately accurate, are of much value will not be disputed by anyone who has made intelligent use of them. The fact that a short time ago a leading surgeon in this state, while discussing the surgical treatment of the stomach, calmly dismissed all chemical tests by saying they were absolutely of no value, simply emphasizes how unsatisfactory the long and complex methods are to the rank and file of the profession, who have neither time nor facilities to make proper use of them. In the examination of no other organ is a definite plan of procedure so important to a correct finding. In every severe or obscure