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Malayalam literature

Malayalam, the lingua franca of the Indian state of Kerala and the union territories of Lakshadweep and Puduchery, is one of the six classical languages of India. Malayalam literature comprises those literary texts written in Malayalam, a South-Dravidian language spoken in the Indian state of Kerala. The first travelogue in any Indian language is the Malayalam Varthamanappusthakam, written by Paremmakkal Thoma Kathanar in 1785. Malayalam literature has been presented with 6 Jnanapith awards, the second-most for any Dravidian language and the third-highest for any Indian language.

The Sangam literature can be considered as the ancient predecessor of Malayalam. The origin of Malayalam calendar dates back to year 825 CE. It is generally agreed that the Quilon Syrian copper plates of 849/850 CE is the available oldest inscription written in Old Malayalam. The earliest known literary works in Malayalam are Ramacharitam (late 12th or early 13th century) and Thirunizhalmala, two epic poems written in Old Malayalam. In the subsequent centuries, besides a popular Pattu ("song") literature, the manipravalam poetry also flourished. Manipravalam (translates "ruby coral") style consisted of poetry in an admixture of Malayalam and Sanskrit. Then came works such as champus and sandeshakavyas in which prose and poetry were interspersed. Later, poets like Cherusseri introduced poems on devotional themes.

Designated a "Classical Language in India" in 2013, Malayalam literature developed into the current form mainly by the influence of the poets Cherusseri Namboothiri, Thunchaththu Ezhuthachan, and Poonthanam Nambudiri, in the 15th and the 16th centuries of Common Era. Thunchathu Ezhuthachchan is also known as The father of modern Malayalam literature. Kunchan Nambiar, a poet of 18th century CE, also has contributed much to Malayalam literature in its early form. The Bharathappuzha river, also known as River Ponnani, and its tributaries, have played a major role in the development of modern Malayalam Literature. There were also other important works, in Arabi Malayalam like Muhyadheen Mala, which was also produced in 16th-17th centuries of Common Era. The growth of Arabi Malayalam literature eventually lead to Mappila Songs. The words used in many of the Arabi Malayalam works those date back to 16th-17th centuries of Common Era are also very closer to the modern Malayalam language. Ezhuthachan, a strong proponent of Bhakti movement, is known as the father of Malayalam. His poems are classified under the genre of kilippattu.

The prose literature, criticism, and Malayalam journalism began after the latter half of the 18th century CE. Contemporary Malayalam literature deals with social, political, and economic life context. Modern literary movements in Malayalam literature began in the late 19th century with the rise of the famous Modern Triumvirate consisting of Kumaran Asan, Ulloor S. Parameswara Iyer and Vallathol Narayana Menon. Kumaran Asan was temperamentally a pessimist—a disposition reinforced by his metaphysics—yet all his life was active in promoting his downtrodden Hindu-Ezhava community. Ullor wrote in the classical tradition, appealing for universal love, while Vallathol responded to the human significance of social progress. Contemporary Malayalam poetry deals with social, political, and economic life context. The tendency of the modern poetry is often towards political radicalism. In the second half of the 20th century, Jnanpith winning poets and writers like G. Sankara Kurup, S. K. Pottekkatt, Thakazhi Sivasankara Pillai, Edasseri Govindan Nair, M. T. Vasudevan Nair, O. N. V. Kurup, and Akkitham Achuthan Namboothiri, had made valuable contributions to the modern Malayalam literature. Later, writers like O. V. Vijayan, Kamaladas, M. Mukundan, Arundhati Roy, and Vaikom Muhammed Basheer, have gained international recognition. The modern Malayalam grammar is based on the book Kerala Panineeyam written by A. R. Raja Raja Varma in the late 19th century CE.

Evolution of Malayalam

The western dialect of Old Tamil spoken in the southwestern Malabar Coast of India was known as Malanaattu Tamil/Malabar Tamil (Meaning the Tamil of the hilly region/the Tamil of Malabar) since the ancient Sangam period (300 BCE - 300 CE). Due to the geographical separation of the Malabar Coast from Tamil Nadu, and the presence of Western Ghats mountain ranges in between these two geographical regions, the dialect of Tamil spoken in the territory of the western Malabar Coast of the ancient Chera kingdom was different from that spoken in the Tamil-mainland. The generally held view is that Malayalam was the western coastal dialect Middle Tamil and started separation from Proto-Tamil-Malayalam sometime in the 8th century CE. The renowned poets of Classical Tamil such as Paranar (1st century CE), Ilango Adigal (2nd-3rd century CE), and Kulasekhara Alvar (9th century CE) were Keralites. The Sangam literature can be considered as the ancient predecessor of Malayalam.

Some scholars however believe that both Tamil and Malayalam developed during the prehistoric period from a common ancestor, 'Proto-Tamil-Malayalam', and that the notion of Malayalam being a 'daughter' of Tamil is misplaced. This is based on the fact that Malayalam and several Dravidian languages on the western coast have common archaic features which are not found even in the oldest historical forms of literary Tamil. However they share few striking innovations with Middle Tamil thus making independent descent impossible.

Old Malayalam (Pazhaya Malayalam), an inscriptional language found in Kerala from c. 9th to c. 13th century CE, is the earliest attested form of Malayalam. The start of the development of Old Malayalam from a western coastal dialect of contemporary Tamil (Middle Tamil) can be dated to c. 7th - 8th century CE. It remained a west coast dialect until c. 9th century CE or a little later. The origin of Malayalam calendar dates back to year 825 CE. The formation of the language is mainly attributed to geographical separation of Kerala from the Tamil country and the influence of immigrant Tulu-Canarese Brahmins in Kerala (who also knew Sanskrit and Prakrit). It is generally agreed that the western coastal dialect of Tamil began to separate, diverge, and grow as a distinct language, mainly due to the heavy influence of Sanskrit and Prakrit, those became common prominent languages on Malabar Coast, when the caste system became strong in Kerala under Nambudiri Brahmins.

The Old Malayalam language was employed in several official records and transactions (at the level of the Chera Perumal kings as well as the upper-caste (Nambudiri) village temples). Most of the inscriptions in Old Malayalam were found from the northern districts of Kerala, those lie adjacent to Tulu Nadu. Old Malayalam was mostly written in Vatteluttu script (with Pallava/Southern Grantha characters). Old Malayalam had several features distinct from the contemporary Tamil, which include the Nasalisation of adjoining sounds, Substitution of palatal sounds for dental sounds, Contraction of vowels, and the Rejection of gender verbs.

The Old Malayalam got gradually developed into Middle Malayalam (Madhyakaala Malayalam) by the 13th century CE. The Malayalam literature also completely got diverged from Tamil literature by this period. Kannassa Ramayanam and Kannassa Bharatham by Rama Panikkar of the Niranam poets who lived between 1350 and 1450, are representative of this language. The Champu Kavyas written by Punam Nambudiri, one among the Pathinettara Kavikal (Eighteen and a half poets) in the court of the Zamorin of Calicut, also belong to Middle Malayalam. The literary works of this period were heavily influenced by Manipravalam, which was a combination of contemporary Malayalam and Sanskrit. The scripts of Kolezhuthu and Malayanma were also used to write Middle Malayalam, in addition to Vatteluthu and Grantha script those were used to write Old Malayalam.

The Middle Malayalam was succeeded by Modern Malayalam (Aadhunika Malayalam) by the 15th century CE. The poem Krishnagatha written by Cherusseri Namboothiri, who was the court poet of the king Udaya Varman Kolathiri (1446 – 1475) of Kolathunadu, is written in modern Malayalam. The language used in Krishnagatha is the modern spoken form of Malayalam. During the 16th century CE, Thunchaththu Ezhuthachan from the Kingdom of Tanur and Poonthanam Nambudiri from the Kingdom of Valluvanad followed the new trend initiated by Cherussery in their poems. The Adhyathmaramayanam Kilippattu and Mahabharatham Kilippattu written by Ezhuthachan and Jnanappana written by Poonthanam are also included in the earliest form of Modern Malayalam. It is Thunchaththu Ezhuthachan who is also credited with the development of Malayalam script into the current form through the intermixing and modification of the erstwhile scripts of Vatteluttu, Kolezhuthu, and Grantha script, which were used to write the inscriptions and literary works of Old and Middle Malayalam. He further eliminated excess and unnecessary letters from the modified script. Hence, Ezhuthachan is also known as The Father of modern Malayalam. The development of modern Malayalam script was also heavily influenced by the Tigalari script, which was used to write the Tulu language, due to the influence of Tuluva Brahmins in Kerala. The currently adopted Malayalam script is the only script in India that can be used to write any other language of India as it contain letters to denote both of the Voiced retroflex approximant (/ɻ/) (which is unique to Tamil and Malayalam in India) and the letters unique to Sanskrit (those are not there in the Tamil script). The language used in the Arabi Malayalam works of 16th-17th century CE is a mixture of Modern Malayalam and Arabic. They follow the syntax of modern Malayalam, though written in a modified form of Arabic script, which is known as Arabi Malayalam script.

Kunchan Nambiar introduced a new literary form called Thullal, and Unnayi Variyar introduced reforms in Attakkatha literature. Modern literary movements in Malayalam literature began in the late 19th century with the rise of the famous Modern Triumvirate consisting of Kumaran Asan, Ulloor S. Parameswara Iyer and Vallathol Narayana Menon. The printing, prose literature, and Malayalam journalism, developed after the latter-half of the 18th century CE. In the second half of the 20th century, Jnanpith winning poets and writers like G. Sankara Kurup, S. K. Pottekkatt, Thakazhi Sivasankara Pillai, Edasseri Govindan Nair, M. T. Vasudevan Nair, O. N. V. Kurup, and Akkitham Achuthan Namboothiri, had made valuable contributions to the modern Malayalam literature. Later, writers like O. V. Vijayan, Kamaladas, M. Mukundan, Arundhati Roy, Vaikom Muhammed Basheer, have gained international recognition. Malayalam has also borrowed a lot of its words from various foreign languages, mainly from the Semitic languages including Arabic, and the European languages including Dutch and Portuguese, due to the long heritage of Indian Ocean trade and the Portuguese-Dutch colonisation in the Malabar Coast.

Folk Songs
Folk songs are the oldest literary form in Malayalam. They were just oral songs. Many of them were related to agricultural activities, including Pulayar Pattu, Pulluvan Pattu, Njattu Pattu, Koythu Pattu, etc. Other Ballads of Folk Song period include the Vadakkan Pattukal (Northern songs) in North Malabar region and the Thekkan Pattukal (Southern songs) in Southern Travancore. Some of the earliest Mappila songs (Muslim songs) were also folk songs. For the first 600 years of the Malayalam calendar, Malayalam literature remained in a preliminary stage. During this time, Malayalam literature consisted mainly of various genres of songs (Pattu). Prominent were songs praising the goddesses of the land, ballads of brave warriors, songs related to the work of a particular caste and songs intended just for entertainment. Bhadrakali pattu, thottam pattu,Mappila pattu, mavaratham pattu, sasthanga pattu, nizhalkoothu pattu, sarpa pattu, sastham pattu, thiyyattu pattu, pulluvar pattu, mannar pattu, panar pattu, krishi pattu, thamburan pattu, pada pattu, villadichan pattu, onappattu, kummi and lullaby were some of the major subgenres. These names were not used historically, but are used in modern times to describe the song genres of that time.

Ramacharitham
Ramacharitham is a collection of poems written at the end of the preliminary stage. It is the oldest Malayalam book available, with a possible exception of Thirunizhalmala. The collection has 1,814 poems in it. Ramacharitham mainly consists of stories from the Yuddha Kanda of the Ramayana. It was written by a poet with the pen name Cheeramakavi who, according to poet Ulloor S Parameswara Iyer, was Sree Veerarama Varman, a king of southern Kerala from AD 1195 to 1208. However the claim that it was written in Southern Kerala is expired on the basis of new discoveries. Other experts, like Chirakkal T Balakrishnan Nair, Dr. K.M. George, M. M. Purushothaman Nair, and P.V. Krishnan Nair, state that the origin of the book is in Kasaragod district in North Malabar region. They cite the use of certain words in the book and also the fact that the manuscript of the book was recovered from Nileshwaram in North Malabar. The influence of Ramacharitam is mostly seen in the contemporary literary works of Northern Kerala. The words used in Ramacharitam such as Nade (Mumbe), Innum (Iniyum), Ninna (Ninne), Chaaduka (Eriyuka) are special features of the dialect spoken in North Malabar (Kasaragod-Kannur region). Furthermore, the Thiruvananthapuram mentioned in Ramacharitham is not the Thiruvananthapuram in Southern Kerala. But it is Ananthapura Lake Temple of Kumbla in the northernmost Kasaragod district of Kerala. The word Thiru is used just by the meaning Honoured. Today it is widely accepted that Ramacharitham was written somewhere in North Malabar (most likely near Kasaragod). Ramacharitham is considered a book written during the formative years of Malayalam. According to Rev. Dr. Hermann Gundert, who compiled the first dictionary of the Malayalam language, Ramacharitham shows the ancient style of the Malayalam language.

Manipravalam
While the Pattu school flourished among certain sections of the society, the literature of the elite was composed in the curious mixture of Sanskrit and Malayalam which is referred to as Manipravalam, mani meaning ruby (Malayalam) and pravalam meaning coral (Sanskrit). Lilathilakam, a work on grammar and rhetoric, written in the last quarter of the 14th century discusses the relationship between Manipravalam and Pattu as poetic forms. It lays special emphasis on the types of words that blend harmoniously. It points out that the rules of Sanskrit prosody should be followed in Manipravalam poetry. This particular school of poetry was patronised by the upper classes, especially the Nambudiris. Dramatic performances given in Koothambalams, known by the names of Koothu and Koodiyattom, often used Sanskrit and Malayalam. In Koodiyattom, the clown (vidooshaka) is allowed to use Malayalam while the hero recites slokas in Sanskrit. Tholan, a legendary court poet in the period of the Kulasekhara kings, is believed to have started this practice.

The earliest of these works in the Manipravalam school is Vaisika Tantram written in the 13th century. It contains about 200 quatrains in Sanskrit metres and is in the form of professional advice given to a prostitute or courtesan by her mother. Each quatrain is composed with care and due weight is given to the rules of rhetoric. Several quatrains of this type are quoted in Lilathilakam by way of illustration for the several rules of grammar and rhetoric.

The most representative of the early Manipravalam works are the tales of courtesans (Achi Charitams) and the Message Poems (Sandesa Kavyas). Unniyachi Charitam, Unnichiruthevi Charitam and Unniyadi Charitam are examples of the former type which is known by the name champu. The Padya (verse) portion is in Sanskrit metres and the Gadya (prose) portion is mostly in Dravidian metres. Authorship of Unniyachi Charitam and Unnichiruthevi Charitam is not known and only a portion of the works is now available. Unniyadi Charitam, which also exists in a fragmented form, is supposed to be written by Damodara Chakkiar. The Sandesa Kavyas are an important poetic genre in Sanskrit, and on the model of Kalidasa's Meghadūta and Lakshmidasa's Sukasandesa, a number of message poems came to be written first in Manipravalam and later in pure Malayalam. The best known among these sandesas is perhaps Unnuneeli Sandesam written in the 14th century. The poem is written under the pen-name Amruthanilakshi, and some believe that it was written in 1362 CE. The exact identity of the author remains a mystery, but it is widely believed that one of the members of the Travancore Royal Family wrote it.

The next work to be mentioned is Ramakathapattu, as it is popularly known, though the author calls it Ramayanakavyam. The author is Ayyappilli Asan who lived sometime about 1400 CE at Auvatutura near Kovalam and whom P. K. Narayana Pillai, who discovered the full text of the book in 1965, calls "the Homer of Malayalam." Ramakathapattu contains 3163 songs in 279 Vrittas or parts.

Niranam poets
While the Manipravala poetry flourished as a diversion from the mainstream, the tradition set up by Cheeraman of Ramacharitamand the more enlightened among the anonymous folk poets was resumed and replenished by three writers commonly referred to as Niranam poets, being Madhava Panikkar, Sankara Panikkar and Rama Panikkar. They were influenced by the Bhakti movement. The Bhakti school was thus revived, and in the place of the excessive sensuality and eroticism of the Manipravalam poets, the seriousness of the poetic vocation was reasserted by them. It is believed that they all belonged to the same Kannassa family and that Madhava Panikkar and Sankara Panikkar were the uncles of Rama Panikkar, the youngest of the three. Their most important work is Kannasa Ramayanam which is an important link between Ramacharitam, Ramakathapattu and Ezhuthachan's Adhyathmaramayanam. Ulloor has said that Rama Panikkar holds the same position in Malayalam literature that Edmund Spenser has in English literature.

Later Champus and Krishnagatha
The 15th century CE saw two paralleled movements in Malayalam literature: one spearheaded by the Manipravalam works, especially the Champus, and the other emanating from the Pattu school and adumbrated in Cherusseri's magnum opus, Krishnagatha (Song of Krishna). The language of the later Champus reads more like modern Malayalam than that of the earlier Champus and Sandesa Kavyas. Champus were mostly works of satire and hyperbole was a regular feature of it. The greatest Champus of the 15th century is Punam Nambudiri's Ramayanam which uses Puranic themes and episodes unlike the 14th century Champus which were tales of the courtesans. Punam was a court poet of the Zamorin of Calicut. Punam also wrote a Bharatam Champoo. There are also many others, the authorship of which is ascribed to him. The later Champus came to be used for dramatic oral narration by performing artists in their Koothu and Patakam. Mahishamangalam (or Mazhamangalam) Narayanan Nambudiri who lived in the 16th century is the author of some of the best Champus of all time. The most widely known of these is Naishadham followed by Rajaratnavaliyam and Kodia Viraham. Chandrotsavam, whose authorship is unknown, is a long narrative poem written in Manipravalam.

The elitist Manipravala Champu school disappeared by the end of the 16th century. The average readers without much grounding in Sanskrit had their favourite poems and poets in the so-called Pattu school. With the writing of Krishnagatha by Cherusseri, the validity of the use of spoken Malayalam for literary purposes received its ultimate justification. Unlike the language of Ramacharitam and the works of the Niranam poets, the language of Krishnagatha marks the culmination of a stage of evolution. There is some dispute about the author's name and his identity. Some scholars are of opinion that he was the same as the Punam Nambudiri of the Champus. It is widely believed that Cherusseri lived in the 15th century CE and was the court poet of Udayavarma of Kolathunadu.

Arabi Malayalam
The Arabi Malayalam (also called Mappila Malayalam and Moplah Malayalam) was the traditional Dravidian language of the Mappila Muslim community in Malabar Coast. The poets like Moyinkutty Vaidyar and Pulikkottil Hyder have made notable contributions to the Mappila songs, which is a genre of the Arabi Malayalam literature. The Arabi Malayalam script, otherwise known as the Ponnani script,  is a writing system - a variant form of the Arabic script with special orthographic features - which was developed during the early medieval period and used to write Arabi Malayalam until the early 20th century CE. Though the script originated and developed in Kerala, today it is predominantly used in Malaysia and Singapore by the migrant Muslim community.

Evolution of Modern Malayalam
The Middle Malayalam (Madhyakaala Malayalam) was succeeded by Modern Malayalam (Aadhunika Malayalam) by the 15th century CE. The poem Krishnagatha written by Cherusseri Namboothiri, who was the court poet of the king Udaya Varman Kolathiri (1446 – 1475) of Kolathunadu, is written in modern Malayalam. The language used in Krishnagatha is the modern spoken form of Malayalam. During the 16th century CE, Thunchaththu Ezhuthachan from the Kingdom of Tanur and Poonthanam Nambudiri from the Kingdom of Valluvanad followed the new trend initiated by Cherussery in their poems. The Adhyathmaramayanam Kilippattu and Mahabharatham Kilippattu written by Ezhuthachan and Jnanappana written by Poonthanam are also included in the earliest form of Modern Malayalam.

It is Thunchaththu Ezhuthachan who is also credited with the development of Malayalam script into the current form through the intermixing and modification of the erstwhile scripts of Vatteluttu, Kolezhuthu, and Grantha script, which were used to write the inscriptions and literary works of Old and Middle Malayalam. He further eliminated excess and unnecessary letters from the modified script. Hence, Ezhuthachan is also known as The Father of modern Malayalam. The development of modern Malayalam script was also heavily influenced by the Tigalari script, which was used to write the Tulu language, due to the influence of Tuluva Brahmins in Kerala. The language used in the Arabi Malayalam works of 16th-17th century CE is a mixture of Modern Malayalam and Arabic. They follow the syntax of modern Malayalam, though written in a modified form of Arabic script, which is known as Arabi Malayalam script.

P. Shangunny Menon ascribes the authorship of the medieval work Keralolpathi, which describes the Parashurama legend and the departure of the final Cheraman Perumal king to Mecca, to Thunchaththu Ramanujan Ezhuthachan. The currently adopted Malayalam script, adopted by Ezhuthachan can be used to write any other language of India as it contain letters to denote both of the Voiced retroflex approximant (/ɻ/) (which is unique to Dravidian languages in India) and the letters unique to Sanskrit (those are not there in the Tamil script).

Bhakti era
Malayalam literature passed through a tremendous process of development in the 15th and 16th centuries. Cherusseri's Krishnagatha bore witness to the evolution of modern Malayalam language as a proper medium for serious poetic communication. Alongside this, there flourished numerous Sanskrit poets who were very active during this period. The greatest of them was Melpathur Narayana Bhattathiri (1559–1665), the author of Narayaniyam. The most significant development of the time took place in the field of Malayalam poetry. Thunchaththu Ramanujan Ezhuthachan wrote his two great epics Adhyathmaramayanam and Srimahabharatam and two shorter pieces, Irupathinalu Vrittam and Harinama Kirtanam and thereby revolutionised Malayalam language and literature at once. Ezhuthachan refined the style of Malayalam language and it was during his period that Malayalam literature attained its individuality and Malayalam became a fully fledged independent language. Today he is known as the father of Malayalam language and its literature. The Kilippattu form he adopted in Ramayanam and Bharatam may be a pointer to his recognition of the importance of sound effect in poetry. Ezhuthachan is perhaps the greatest spokesman of the Bhakti movement in Malayalam but he is more than a writer of devotional hymns. K. Ayyappa Paniker has noted that "the transition from Cherrusseri to Ezhuthachan marks the triumph of modernism over medievalism." Another important poet of this period was Poonthanam Nambudiri (1547–1640). His chief poems are Jnanappana (The Song of Divine Wisdom), Bhasha Karnamritam and Kumaraharanam or Santanagopalam Pana.

Performance arts
The 16th century also saw the writing of some dramatic works in Manipravalam and pure Malayalam, Bharatavakyam, often described as a choral narration, is a work in Manipravalam which was used for stage performance. The main development in the cultural field in Kerala in the 17th century was the growth of a new form of visual art called Kathakali, which brought into being a new genre of poetry called Attakkatha consisting of the libretto used for a Kathakali performance. The origins of aattakatha literature dates back to the 12th century and it emerged as a literary genre in the 17th century. The earliest of the aattakathas is believed to be a cycle of eight Ramayana stories (collectively known as Ramanattam), composed by Kottarakkara Tampuran and about whose date there is an ongoing controversy. Next in importance are the works of Kottayathu Tampuran whose period is about the middle of the seventeenth century. Since the four aattakathas he wrote Bakavadham, Kalyanasaugandhikam, Kirmeeravadham and Kalakeyavadham punctiliously conform to the strict rules of Kathakali, they are particularly favoured by orthodox artistes and their patrons. Another poet of this category is Irayimman Thampi (1783–1863). Unnayi Variyar's Nalacharitham Aattakatha is one of the most famous works in this genre. Margamkali was the form of ritual and entertainment among the Syrian Christians corresponding to the Sanghakali of the Brahmins. Margamkalippattu is the song for this performance depicting the story of Thomas the Apostle. This was one of the numerous pieces of Christian literature that must have gained currency in the 16th and 17th centuries.

In the court of Travancore king Marthanda Varma (1706–1758) and his successor Dharma Raja Kartika Tirunal Rama Varma, there flourished a number of poets distinguished in several ways. Ramapurathu Warrier (1703–1753), the author of Kuchela Vrittam Vanchippattu, was one of them. The Vanchippattu or Boat song is a poetic form of folk origin composed entirely in the Dravidian metre nathonnata. Kunchan Nambiar (1705–1770), the founder of Thullal and its rich literature, is often considered as the master of Malayalam satirist poetry. Born in Killikkurussimangalam, he spent his boyhood at Kudamalur and youth at Ambalappuzha. 1748 he moved to the court of Marthanda Varma and later to the court of his successor Dharma Raja. The word "Thullal" literally means "dance", but under this name Nambiar devised a new style of verse narration with a little background music and dance-like swinging movement to wean the people away from the Chakkiyar Koothu, which was the art form popular till then. He used pure Malayalam as opposed to the stylised and Sanskritised Malayalam language of Chakkiyar Koothu. He also adopted many elements from Padayani and Kolam Thullal and certain local folk arts. There are three kinds of Tullal distinguished on the basis of the performer's costume and the style of rendering, viz., Ottan, Sitankan and Parayan. Dravidian metres are used throughout although there is a quatrain in a Sanskrit metre.

Prose literature
There was a great lull in the field of literary creation in Malayalam for nearly a century after the death of Kunchan Nambiar. There was however a consistent and steady development of prose at this time. The evolution of prose literature in the early centuries was a very slow process. In the wake of Bhashakautaliyam several translations began to appear in the fifteenth and sixteenth centuries. The prose of Attaprakarams was meant to aid the Chakiyars in learning the art of Koodiyattom. Doothavakyam (14th century CE) is one of the earliest of these works. 15th century Malayalam prose is represented by Brahmanda Puranam, a summary of the original in Sanskrit. A large number of prose works appeared during this period, most of which are either narrative based on puranas and religious works in Sanskrit or commentaries on similar works. With the starting of the first printing presses in the 16th century by Christian missionaries, prose literature received a great boost. Several regional versions of Keralolpathi, tracing the beginnings of Kerala history, began to appear in the 18th century. Paremmakkal Thoma Kathanar (1737–1799) wrote the first travelogue in Malayalam, Varthamanapustakam (Book of News). The works of Christian missionaries like Arnos Patiri (Johann Ernst Hanxleden), 1699–1732) and Paulinose Patiri (John Philip Wesdin, 1748–1806) also led to a widening of the range of topics and themes in Malayalam literature.

Venmani school
The third quarter of the nineteenth century bore witness to the rise of a new school of poets devoted to the observation of life around them and the use of pure Malayalam (Pachcha Malayalam). The major poets of the Venmani school were Venmani Achhan Nambudiripad (1817–1891), Venmani Mahan Nambudiripad (1844–1893), Poonthottam Achhan Nambudiri (1821–1865), Poonthottam Mahan Nambudiri (1857–1896) and the members of the Kodungallur Kovilakam (Royal Family) such as Kodungallur Kunjikkuttan Thampuran. The style of these poets became quite popular for a while and influenced even others who were not members of the group like Velutheri Kesavan Vaidyar (1839–1897) and Perunlli Krishnan Vaidyan (1863–1894). The Venmani school pioneered a style of poetry that was associated with common day themes, and the use of pure Malayalam rather than Sanskrit. The poetry was therefore easily understood by the common man. The works were known for its humour, wit, and lyrical metre.

Modern prose literature
Contemporary Malayalam poetry deals with social, political, and economic life context. The tendency of the modern poetry is often towards political radicalism. Nineteenth century was not a very creative period for Malayalam literature (except towards the end) from the point of view of imaginative writing. The modern Malayalam grammar is based on the book Kerala Panineeyam written by A. R. Raja Raja Varma in the late 19th century CE. But the foundations for the great renaissance that began at the end of the century were laid during this period. The establishment of colleges for imparting English education, the translation of the Bible and other religious works, the compilation of dictionaries and grammars, the formation of the text book committee, the growth of printing presses, the starting of newspapers and periodicals, the introduction of science and technology, the beginning of industrialisation and the awakening of social and political consciousness: these constitute the giant strides towards modernisation. Like his predecessors Swathi Thirunal and Uthram Thirunal, Ayilyam Thirunal (1832–1880) and Visakham Thirunal (1837–1885) were great patrons of letters and were themselves talented writers. Christian missionaries Benjamin Bailey (1805–1871), Joseph Peet, Richard Collins and George Mathen (1819–1870) were responsible for many works on Malayalam language based on western models. Perhaps the most important of these missionaries was Herman Gundert (1814–1893). Born in Stuttgart in Germany and educated at Tübingen and Switzerland, Gundert came to India in 1836. He wrote over twenty books in Malayalam, the most important of which are A Malayalam-English Dictionary, A Grammar of Malayalam, Keralappazhama and Pazhamcholmala. The first authoritative grammar of Malayalam was also Gundert's contribution (1851). This led to the production of a number of grammatical works in Malayalam. Vaikkam Patchu Moothathu (1814–1883) published his Grammar of Malayalam in 1876, Kerala Kaumudi by Kovunni Nedungadi (1831–1889) came out in 1878. This was soon followed by the first history of the language by P. Govinda Pillai (1849–1897) published in 1881. The first work on rhetoric in Malayalam on the European model was brought out by Father Gerad under the title Alankara Sastram in the same year. By the end of the 19th century two different traditions could be clearly distinguished in Malayalam literature: the western school and the oriental or traditionalist school. Writers such as Kerala Varma Valiya Koyithampuran represent the confluence of these two major traditions. His major works include Mayurasandesam (Peacock Message) and the translations of Kalidasa's Abhijñānaśākuntalam (which got him the title of Kerala Kalidasa), and of Von Limburg Brower's Akbar. Meanwhile, many literary magazines were established to encourage all kinds of writers and writings, such as C. P. Achutha Menon's Vidyavinodini, Kandathil Varghese Mappillai's Bhashaposhini and Appan Thampuran's Rasikaranjini.

In the wake of Kerala Varma's translation of Abhijñānaśākuntalam, several attempts were made to translate numerous plays from Sanskrit and English into Malayalam. These plays were seldom acted. The stage conditions of those days were crude and unfit to project a performance. As if irritated by this imitation plays of low quality, P. Rama Kurup wrote Chakki Chankaram (1893). Kerala Varma's nephew A. R. Raja Raja Varma went a step further than his uncle in the promotion of a synthesis between the different trends current in the literature of his time. A professor in the His Highness Maharaja's University College, Thiruvananthapuram, he had to modernise the process of teaching Malayalam language and literature; this made him write books on grammar and rhetoric (which earned him the title of Kerala Panini) and eventually prepare the ground for an enlightened renaissance in Malayalam poetry and literary criticism. A close associate of both Kerala Varma and Raja Raja Varma, K. C. Kesava Pillai wrote Kesaviyam (a mahakavya) and a number of attakkathas. Azhakathu Padmanabha Kurup (1869–1932: author of Ramachandravilasam), Pandalam Kerala Varma (1879–1919: author of Rukmangatha Charitam), Kattakkayam Cherian Mappila (1859 – 1937: author of Sri Yesu Vijayam), Ulloor S. Parameswara Iyer (1877–1949 : author of Umakeralam) and Vallathol Narayana Menon (1879–1958: author of Chitrayogam), all paid their obeisance to this neoclassicist trend.

The developments in prose at this time were very significant, Vengayil Kunhiraman Nayanar (1861–1895), more famous under his pseudonym Kesari, was one of the first to explore the essay form in Malayalam. He was closely associated with periodicals like Kerala Chandrika (started in 1879 at Thiruvananthapuram), Kerala Patrika (started in 1884 by C. Kunhiraman Menon (1854–1936) and Appu Nedungadi (1866–1934) at Kozhikode), Kerala Sanchari (after 1898 under the editorship of Murkoth Kumaran) and the English Journal Malabar Spectator. His Vasanavikriti is considered by historians and literary experts as the first short story in Malayalam literature. It was published in Vidyavinodini in 1891. Along with Nayanar, the pioneers of short stories in Malayalam were Oduvil Kunhikrishna Menon, C. S. Gopala Panicker, Ambadi Narayana Poduval, Chenkulath Cheriya Kunhirama Menon (M. R. K. C.) and Moorkoth Kumaran. Fulmoni Ennum Koruna Ennum Peraya Randu Sthreekalude Katha (Phulmōni ennuṁ kōruṇa ennuṁ pērāya ranṭu strīkaḷuṭe katha), a translation of Hana Catherine Mullens's Bengali novel Fulmoni O Korunar Biboron by Rev. Joseph Peet, is believed to be the first novel printed and released in Malayalam (1858). Ghathakawadham (Ghātakavadhaṁ, 1877) by Rev. Richard Collins was the first novel printed and published in Malayalam with a story based in Kerala and around Malayalis.

The first novel conceived and published in Malayalam was Appu Nedungadi's Kundalatha (1887). Though Kundalatha is not considered a major novel, it gets the pride of place as the first work in the language having the basic characteristics of a novel. O. Chandhu Menon's Indulekha was the first major novel in Malayalam language. It was a landmark in the history of Malayalam literature and initiated the novel as a new flourishing genre. The title refers to the main character in this novel, a beautiful, well educated Nair lady of 18 years. C. V. Raman Pillai's Marthandavarma (1891) had many distinctions: it was the first historical novel in any South Indian languages, first novel from Travancore, first Malayalam novel to be a part of a trilogy and the first Malayalam novel to have a masculine title. Marthandavarma was completed even before Indulekha but could not be published until 1891 owing to lack of finance. The novel recounted the history of Venad (Travancore) during the final period of Rajah Rama Varma's reign and subsequently to the accession of Marthanda Varma. The novel had a film adaptation of the same name in 1933 and was the first Malayalam novel to be adapted into film. During the early 20th century, Malayalam received outstanding novels, either as translations or adaptations of Western literature. The post-independence period saw a fresh start in the history of longer fiction in Malayalam as in many other Indian languages, parallel to the evolution of post-world war fiction in other parts of the world. It was both a break and a continuation. P. Kesava Dev, who was a Communist in the thirties and forties turned away from diehard ideologies and wrote a symbolic novel called Arku Vendi? (For Whose Sake?) in 1950, challenging the philosophy of Stalinist liquidation of political enemies. It had a special significance in the context of the 'Calcutta thesis'. After portraying the class struggle of farm labourers in Randidangazhi (Two Measures) in 1949, Thakazhi Sivasankara Pillai turned away from party politics and produced a moving romance in Chemmeen (Shrimps) in 1956. For S. K. Pottekkatt and Vaikom Muhammad Basheer, who had not dabbled in politics, the continuity is marked in the former's Vishakanyaka (Poison Maid, 1948) and the latter's Ntuppuppakkoranendarnnu (My Grandpa had an Elephant, 1951). The non-political social or domestic novel was championed by P. C. Kuttikrishnan (Uroob) with his Ummachu (1955) and Sundarikalum Sundaranmarum (Men and Women of Charm, 1958). In 1957 Basheer's Pathummayude Aadu (Pathumma's Goat) brought in a new kind of prose tale, which perhaps only Basheer could handle with dexterity. The fifties thus mark the evolution of a new kind of fiction, which had its impact on the short stories as well. This was the auspicious moment for the entry of M. T. Vasudevan Nair and T. Padmanabhan upon the scene. Front runners in the post-modern trend include Kakkanadan, O. V. Vijayan, E. Harikumar, M. Mukundan and Anand. The travelogues written by S. K. Pottekkatt were turning point in the travelogue literature. Prominent literary critics of twentieth century include Kuttikrishna Marar.

In the second half of the 20th century, Jnanpith winning poets and writers like G. Sankara Kurup, S. K. Pottekkatt, Thakazhi Sivasankara Pillai, Edasseri Govindan Nair, M. T. Vasudevan Nair, O. N. V. Kurup, and Akkitham Achuthan Namboothiri, had made valuable contributions to the modern Malayalam literature. Later, writers like O. V. Vijayan, Kamaladas, M. Mukundan, Arundhati Roy, Vaikom Muhammed Basheer, have gained international recognition. Kerala has the highest media exposure in India with newspapers publishing in nine languages, mainly English and Malayalam.

Early prose literature
List of early prose literature in the 19th century.

Plays
Writers like Edasseri Govindan Nair, N. N. Pillai, Cherukad, Thoppil Bhasi, Kavalam Narayana Panicker have contributed much to Malayalam drama.

title: Malayalam literature


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Holstein

Holstein (Holsteen; Holsten; Holsatia) is the region between the rivers Elbe and Eider. It is the southern half of Schleswig-Holstein, the northernmost state of Germany.

Holstein once existed as the German County of Holstein (Grafschaft Holstein; 811–1474), the later Duchy of Holstein (Herzogtum Holstein; 1474–1866), and was the northernmost territory of the Holy Roman Empire. The history of Holstein is closely intertwined with the history of the Danish Duchy of Schleswig (Slesvig). The capital of Holstein is Kiel.

Holstein's name comes from the Holcetae, a Saxon tribe mentioned by Adam of Bremen as living on the north bank of the Elbe, to the west of Hamburg. The name means "dwellers in the wood" or "hill-sitters" (Northern Low Saxon: Hol(t)saten; Holzsassen).

Origins
After the Migration Period of the Early Middle Ages, Holstein was adjacent to the Obotrites on the coast of the Baltic Sea and the land of the Danes in Jutland.

With the conquest of Old Saxony by Charlemagne circa 800, he granted the land north of the Eider River (Schleswig) to the Danes by the Treaty of Heiligen signed in 811. The ownership of what would late become eastern Holstein (districts of Plön and Ostholstein) was given to the Obotrites, namely the Wagrians, and the Saxon elite was deported to various areas of the empire. After 814, however, the Saxons were restored to Western Holstein. The Wagrians were pushed out of the Limes Saxoniae - the new border running from the Elbe River near Boizenburg northwards along the Bille River to the mouth of the Schwentine at the Kiel Fjord and the Baltic Sea. For the following 300 years, Holstein continued to be a part of Saxony.

The County of Holstein
The new county of Holstein was established in 1111; it was first a fief of the Duchy of Saxony, then of the Duchy of Saxe-Lauenburg, and finally of the Prince-Bishopric of Lübeck. With the establishment of the new territorial unit, expansion to the East began and the Wagrians were finally defeated in 1138.

The County of Holstein was ruled by the House of Schaumburg; the first count was Adolf I, Count of Holstein. Holstein was temporarily occupied by Denmark after the Battle of Stellau (1201), but was reconquered by the Count of Schauenburg and his allies in the Battle of Bornhöved (1227).

Partitions of the County of Holstein (1111–1474)
The Counts of Schauenburg and Holstein partitioned Holstein several times among the inheriting sons into up to six lines, named after their towns of residence:
 * Holstein-Itzehoe, branch county between 1261 and 1290, partitioned from Holstein, repartitioned into Holstein-Pinneberg, Holstein-Plön and Holstein-Rendsburg
 * Holstein-Kiel, branch county between 1261 and 1390, partitioned from Holstein, in 1273 Holstein-Segeberg (first) was partitioned from Holstein-Kiel, but reverted in 1308, but then lost to Holstein-Pinneberg, Holstein-Plön and Holstein-Rendsburg in 1316; Holstein-Kiel acquired Holstein-Plön in 1350, and merged itself into Holstein-Rendsburg
 * Holstein-Pinneberg, branch county between 1290 and 1640, partitioned from Holstein-Itzehoe, acquired a share of Holstein-Segeberg in 1316, merged into the Duchy of Holstein
 * Holstein-Plön, branch county between 1290 and 1390, partitioned from Holstein-Itzehoe, acquired a share of Holstein-Segeberg in 1316, merged into Holstein-Kiel
 * Holstein-Rendsburg, branch county between 1290 and 1474, partitioned from Holstein-Itzehoe, acquired a share of Holstein-Segeberg (first) in 1316, and Holstein-Kiel in 1390, in 1381/1384 Holstein-Segeberg (second) was partitioned from Holstein-Rendsburg, but reverted in 1403, elevated to ducal rank in 1474
 * Holstein-Segeberg (first), branch county between 1273 and 1308, partitioned from and reverted to Holstein-Kiel, but seized by allied Holstein-Pinneberg, Holstein-Plön, and Holstein-Rendsburg, partitioning Segeberg in three shares, each merged into one of the lines in 1316
 * Holstein-Segeberg (second), branch county between 1381/1384 and 1403, partitioned from and reverted to Holstein-Rendsburg

In 1386 King Oluf II of Denmark and his mother, Queen Margaret I, enfeoffed in Nyborg Gerhard VI, Count of Holstein-Rendsburg and his cognatic successors with the Duchy of Schleswig. He thus became as Gerhard II duke of Schleswig. Until 1390 the Rendsburg branch united by inheritance all branches except of that of Holstein-Pinneberg.

When the Holstein-Rendsburg line of the Schauenburg counts became extinct with the death of Adolf VIII of Holstein-Rendsburg (and in personal union as Adolf I Duke of Schleswig) in 1459, Christian I of Denmark inherited – from his maternal uncle Adolf I – the Duchy of Schleswig, a Danish fief. Through the Treaty of Ribe (1460) Christian was elected Count of Holstein-Rendsburg, then still a Saxe-Lauenburgian subfief within the Holy Roman Empire.

The Duchy of Holstein
In 1474 Lauenburg's liege lord, the German Emperor Frederick III, elevated Christian I as Count of Holstein-Rendsburg to Duke of Holstein, thus becoming an immediate imperial (reichsunmittelbar) vassal (see imperial immediacy). The Duchy of Holstein retained that status until the dissolution of the Empire in 1806.

Partitions of the Duchy of Holstein (1474–1866)
In 1490, the Duchy of Holstein was divided into Holstein-Segeberg and Holstein-Gottorp. Holstein-Segeberg remained with the Danish king and was also known as Royal Holstein; later it came to be known as Holstein-Glückstadt. Holstein-Gottorp, also known as Ducal Holstein, was given to a cadet branch of the House of Oldenburg, to which the kings of Denmark belonged.

Between 1533 and 1544 King Christian III of Denmark ruled the entire Duchies of Holstein and of Schleswig also in the name of his then still minor half-brothers John the Elder and Adolf. In 1544 they partitioned the Duchies of Holstein (a fief of the Holy Roman Empire) and of Schleswig (a Danish fief) in an unusual way, following negotiations between the brothers and the Estates of the Realm of the duchies, which had constituted in 1460 by the Treaty of Ribe and strictly opposed a factual partition. The elder three brothers determined their youngest brother Frederick for a career as Lutheran administrator of an ecclesiastical state within the Holy Roman Empire.

So the revenues of the duchies were divided in three equal shares by assigning the revenues of particular areas and landed estates to each of the elder brothers, while other general revenues, such as taxes from towns and customs dues, were levied together but then shared among the brothers. The estates, whose revenues were assigned to the parties, made Holstein and Schleswig look like patchworks, technically inhibiting the emergence of separate new duchies, as intended by the estates of the duchies. The secular rule in the fiscally divided duchies thus became a condominium of the parties. As dukes of Holstein and Schleswig the rulers of both houses bore the formal title of "Duke of Schleswig, Holstein, Ditmarsh and Stormarn". The three shares are usually called:

 * Gottorp ducal share in Holstein and Schleswig, partitioned from ducal Holstein in 1544, acquired half of Haderslev share in 1581 (thus thereafter simply called ducal share), merged into the royal share in 1773 with its ruler receiving in return the prior Danish-held County of Oldenburg.
 * Haderslev ducal share in Holstein and Schleswig, partitioned from ducal Holstein in 1544, halved between Gottorp and royal share in 1581
 * Royal share in Holstein and Schleswig, acquired half of Haderslev share in 1581, the County of Holstein-Pinneberg in 1640 and the Gottorp share in 1713 (northern part) and 1773 (southern part), thus then comprising all of Holstein. Between 1648 and 1773 the royal share used to be called Holstein-Glückstadt after its capital Glückstadt. Parts of the former County of Holstein-Pinneberg were transformed 1649/50 into the Imperial County of Rantzau, which fell back to the Danish Crown in 1726.

The dynastic name Holstein-Gottorp comes as convenient usage from the technically more correct Duke of Schleswig and Holstein at Gottorp. Adolf, the third son of Duke and King Frederick I and the second youngest half-brother of King Christian III, founded the dynastic branch called House of Holstein-Gottorp, which is a cadet branch of the then royal Danish House of Oldenburg. The Danish monarchs and the Dukes of Holstein-Gottorp ruled both duchies together as to general government, however, collected their revenues in their separate estates. John the Elder conveniently called Duke of Schleswig-Holstein-Haderslev produced no issue, so no branch emerged from his side.

Similar to the above-mentioned agreement Christian III's youngest son John the Younger gained for him and his heirs a share in Holstein's and Schleswig's revenues in 1564, comprising a third of the royal share, thus a ninth of Holstein and Schleswig as to the fiscal point of view. John the Younger and his heirs, however, had no share in the condominial rule, so they were not ruling but mere titular dukes.

The share of John the Elder, who died in 1581, was halved between Adolf and Frederick II, thus increasing again the royal share by a fiscal sixth of Holstein and Schleswig. As an effect the complicated fiscal division of both separate duchies, Holstein and Schleswig, with shares of each party scattered in both duchies, provided them with a condominial government binding both together, partially superseding their legally different affiliation as Holy Roman and Danish fiefs.

The County of Holstein-Pinneberg, which had remained a separately ruled territory in Holstein until its line was extinct in 1640, was merged into the then royal share of the Duchy of Holstein. The Duke of Holstein-Gottorp became emperor of Russia in 1762 as Peter III and was planning an attack on Denmark to recover the Holstein-Gottorp lands possessions in Schleswig, which were seized by the Danish king in 1713. Although Peter was soon overthrown by his wife, Catherine the Great, the Danes determined to rid themselves of this problem. In 1773, they exchanged the County of Oldenburg for the Gottorp lands in Holstein, bringing all of Holstein under their control. Thus, Holstein was again united in one state. The territory of Holstein was enlarged by the conquest of the independent Republic of Dithmarschen in 1559, which was divided among the three ducal houses. After 1581 the southern part remained to the Danish Crown, the northern part was ruled by the House of Gottorp until 1773.

United Holstein
With the dissolution of the Holy Roman Empire in 1806 Holstein's imperial vassal status turned void. It thus became a sovereign state. Because of its personal union with Denmark, the Duchy of Holstein did not come under French occupation during the Napoleonic era (however, the neighboring duchy of Lauenburg was annexed by France in 1811 and became a part of Bouches-de-l'Elbe). From 1815 to 1864 it was a member of the German Confederation, though still in personal union with Denmark (the King of Denmark being also Duke of Holstein).

Following the death of King Frederick VII of Denmark (House of Oldenburg) in 1863, the inheritance of Schleswig and Holstein was disputed. The new king, Christian IX (House of Schleswig-Holstein-Sonderburg-Glücksburg, a cadet branch of the House of Oldenburg), made his claim to the Danish throne through a female line. The Duke of Augustenborg, a minor scion from another cadet line of the House of Oldenburg, claimed the Duchies, and soon the German Confederation, led by Prussia and Austria, went to the Second Schleswig War with Denmark, quickly defeating it in 1864 and forcing it to cede the duchies.

However, the duchies were not given to the Duke of Augustenborg. In 1865 an arrangement was worked out between Prussia and Austria where the Austrians occupied and administered Holstein, while the Prussians did the same in Schleswig. This arrangement came to an end with the Austro-Prussian War of 1866, which resulted in Schleswig and Holstein both being incorporated into Prussia as the Province of Schleswig-Holstein. Holstein, meanwhile including former Saxe-Lauenburg (as of 1876) and the former Free and Hanseatic City of Lübeck and Region of Lübeck (both as of 1937) regained statehood, now united with Schleswig, in 1946, when the British occupation government elevated the province to the State of Schleswig-Holstein, followed by the official dissolution of Prussia in 1947.

For a list of rulers, see Counts of Schauenburg and Holstein and List of rulers of Schleswig-Holstein.

Geography
As of 1864, Holstein bordered Denmark in the north, the Principality of Lübeck (formerly the Prince-Bishopric of Lübeck, an exclave of the Grand Duchy of Oldenburg), the Free and Hanseatic City of Lübeck, and the Duchy of Saxe-Lauenburg in the east, and the Kingdom of Hanover and the Free and Hanseatic City of Hamburg in the south. It also borders the North Sea in the west and the Baltic Sea in the east. Its only major island is Fehmarn, originally a part of the Duchy of Schleswig until 1867.

Cities in Holstein included Kiel, Altona, Glückstadt, Rendsburg, Segeberg, Heiligenhafen, Oldenburg in Holstein, and Plön. It had an area of 8,385 km2.

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Holstein


text:
Fecal incontinence

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred to as anal incontinence. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery (especially involving the anal sphincters or hemorrhoidal vascular cushions), altered bowel habits (e.g., caused by irritable bowel syndrome, Crohn's disease, ulcerative colitis, food intolerance, or constipation with overflow incontinence). An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

Fecal incontinence has three main consequences: local reactions of the perianal skin and urinary tract, including maceration (softening and whitening of the skin due to continuous moisture), urinary tract infections, or decubitus ulcers (pressure sores); a financial expense for individuals (due to the cost of medication and incontinence products, and loss of productivity), employers (days off), and medical insurers and society generally (health care costs, unemployment); and an associated decrease in quality of life. There is often reduced self-esteem, shame, humiliation, depression, a need to organize life around easy access to a toilet, and avoidance of enjoyable activities. FI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse. People may be too embarrassed to seek medical help and attempt to self-manage the symptom in secrecy from others.

FI is one of the most psychologically and socially debilitating conditions in an otherwise healthy individual and is generally treatable. More than 50% of hospitalized seriously ill patients rated bladder or fecal incontinence as "worse than death". Management may be achieved through an individualized mix of dietary, pharmacologic, and surgical measures. Health care professionals are often poorly informed about treatment options, and may fail to recognize the effect of FI.

Signs and symptoms
FI affects virtually all aspects of peoples' lives, greatly diminishing physical and mental health, and affecting personal, social, and professional life. Emotional effects may include stress, fearfulness, anxiety, exhaustion, fear of public humiliation, feeling dirty, poor body image, reduced desire for sex, anger, humiliation, depression, isolation, secrecy, frustration, and embarrassment. Some patients cope by controlling their emotions or behavior. Physical symptoms such as skin soreness, pain and odor may also affect quality of life. Physical activity such as shopping or exercise is often affected. Travel may be affected, requiring careful planning. Working is also affected for most. Relationships, social activities and self-image likewise often suffer. Symptoms may worsen over time.

Causes
FI is a sign or a symptom, not a diagnosis, and represents an extensive list of causes. Usually, it is the result of a complex interplay of several coexisting factors, many of which may be simple to correct. Up to 80% of people may have more than one abnormality that is contributing. Deficits of individual functional components of the continence mechanism can be partially compensated for a certain period, until the compensating components themselves fail. For example, obstetric injury may precede onset by decades, but postmenopausal changes in the tissue strength reduce in turn the competence of the compensatory mechanisms. The most common factors in the development are thought to be obstetric injury and after-effects of anorectal surgery, especially those involving the anal sphincters and hemorrhoidal vascular cushions. The majority of incontinent persons over the age of 18 fall into one of several groups: those with structural anorectal abnormalities (sphincter trauma, sphincter degeneration, perianal fistula, rectal prolapse), neurological disorders (multiple sclerosis, spinal cord injury, spina bifida, stroke, etc.), constipation/fecal loading (presence of a large amount of feces in the rectum with stool of any consistency), cognitive and/or behavioral dysfunction (dementia, learning disabilities), diarrhea, inflammatory bowel diseases (e.g. ulcerative colitis, Crohn's disease), irritable bowel syndrome, disability related (people who are frail, acutely unwell, or have chronic/acute disabilities), and those cases which are idiopathic (of unknown cause). Diabetes mellitus is also known to be a cause, but the mechanism of this relationship is not well understood.

Congenital
Anorectal anomalies and spinal cord defects may be a cause in children. These are usually picked up and operated upon during early life, but continence is often imperfect thereafter.

Anal canal
The functioning of the anal canal can be damaged, traumatically or atraumatically. The resting tone of the anal canal is not the only important factor; both the length of the high-pressure zone and its radial translation of force are required for continence. This means that even with normal anal canal pressure, focal defects such as the keyhole deformity can be the cause of substantial symptoms. External anal sphincter (EAS) dysfunction is associated with impaired voluntary control, whereas internal anal sphincter (IAS) dysfunction is associated with impaired fine-tuning of fecal control. Lesions which mechanically interfere with, or prevent the complete closure of the anal canal can cause a liquid stool or mucous rectal discharge. Such lesions include piles (inflamed hemorrhoids), anal fissures, anal cancer, or fistulae. Obstetric injury may tear the anal sphincters, and some of these injuries may be occult (undetected). The risk of injury is greatest when labor has been especially difficult or prolonged, when forceps are used, with higher birth weights, or when a midline episiotomy is performed. Only when there is post-operative investigation of FI such as endoanal ultrasound is the injury discovered. FI is a much under-reported complication of surgery. The IAS is easily damaged with an anal retractor (especially the Park's anal retractor), leading to reduced resting pressure postoperatively. Since the hemorrhoidal vascular cushions contribute 15% of the resting anal tone, surgeries involving these structures may affect continence status. Partial internal sphincterotomy, fistulotomy, anal stretch (Lord's operation), hemorrhoidectomy or transanal advancement flaps may all lead to FI postoperatively, with soiling being far more common than solid FI. The "keyhole deformity" refers to scarring within the anal canal and is another cause of mucus leakage and minor incontinence. This defect is also described as a groove in the anal canal wall and may occur after posterior midline fissurectomy or fistulotomy, or with lateral IAS defects. Rare causes of traumatic injury to the anal sphincters include military or traffic accidents complicated by pelvic fractures, spine injuries or perineal lacerations, insertion of foreign bodies in the rectum, and sexual abuse. Nontraumatic conditions causing anal sphincter weakness include scleroderma, damage to the pudendal nerves, and IAS degeneration of unknown cause. Radiation-induced FI may involve the anal canal as well as the rectum, when proctitis, anal fistula formation, and diminished function of internal and external sphincter occur. Irradiation may occur during radiotherapy, e.g. for prostate cancer.

Pelvic floor
Many people with FI have a generalized weakness of the pelvic floor, especially puborectalis. A weakened puborectalis leads to widening of the anorectal angle and impaired barrier to the stool in the rectum entering the anal canal, and this is associated with incontinence to solids. Abnormal descent of the pelvic floor can also be a sign of pelvic floor weakness. Abnormal descent manifests as descending perineum syndrome (>4 cm perineal descent). This syndrome initially gives constipation, and later FI. The pelvic floor is innervated by the pudendal nerve and the S3 and S4 branches of the pelvic plexus. With recurrent straining, e.g. during difficult labour or long-term constipation, then stretch injury can damage the nerves supplying levator ani. The pudendal nerve is especially vulnerable to irreversible damage, (stretch-induced pudendal neuropathy) which can occur with a 12% stretch. If the pelvic floor muscles lose their innervation, they cease to contract and their muscle fibres are in time replaced by fibrous tissue, which is associated with pelvic floor weakness and incontinence. Increased pudendal nerve terminal motor latency may indicate pelvic floor weakness. The various types of pelvic organ prolapse (e.g. external rectal prolapse, mucosal prolapse and internal rectal intussusception & solitary rectal ulcer syndrome) may also cause coexisting obstructed defecation.

Rectum
The rectum needs to be of a sufficient volume to store stool until defecation. The rectal walls need to be "compliant" i.e. able to distend to an extent to accommodate stool. Rectal sensation is required to detect the presence, nature, and amount of rectal contents. The rectum must also be able to evacuate its contents fully. There must also be efficient coordination of rectal sensation and relaxation of the anal canal. If the sensory nerves are damaged, the detection of stool in the rectum is dulled or absent, and the person will not feel the need to defecate until too late. Rectal hyposensitivity may manifest as constipation, FI, or both. Rectal hyposensitivity was reported to be present in 10% of people with FI. Pudendal neuropathy is one cause of rectal hyposensitivity and may lead to fecal loading/impaction, megarectum and overflow FI. Normal evacuation of rectal contents is 90–100%. If there is incomplete evacuation during defecation, residual stool will be left in the rectum and threaten continence once defecation is finished. This is a feature of people with soiling secondary to obstructed defecation. Obstructed defecation is often due to anismus (paradoxical contraction or relaxation failure of the puborectalis). Whilst anismus is largely a functional disorder, organic pathologic lesions may mechanically interfere with rectal evacuation. Other causes of incomplete evacuation include non-emptying defects like a rectocele. Straining to defecate pushes stool into the rectocele, which acts like a diverticulum and causes stool sequestration. Once the voluntary attempt to defecate, albeit dysfunctional, is finished, the voluntary muscles relax, and residual rectal contents are then able to descend into the anal canal and cause leaking.

Central nervous system
Continence requires conscious and subconscious networking of information from and to the anorectum. Defects/brain damage may affect the central nervous system focally (e.g. stroke, tumor, spinal cord lesions, trauma, multiple sclerosis) or diffusely (e.g. dementia, multiple sclerosis, infection, Parkinson's disease or drug-induced). FI (and urinary incontinence) may also occur during epileptic seizures. Dural ectasia is an example of a spinal cord lesion that may affect continence.

Diarrhea
Liquid stool is more difficult to control than formed, solid stool. Hence, FI can be exacerbated by diarrhea. Some consider diarrhea to be the most common aggravating factor. Where diarrhea is caused by temporary problems such as mild infections or food reactions, incontinence tends to be short-lived. Chronic conditions, such as irritable bowel syndrome or Crohn's disease, can cause severe diarrhea lasting for weeks or months. Diseases, drugs, and indigestible dietary fats that interfere with the intestineal absorption may cause steatorrhea (oily rectal discharge & fatty diarrhea) and degrees of FI. Respective examples include cystic fibrosis, orlistat, and olestra. Postcholecystectomy diarrhea is diarrhea that occurs following gall bladder removal, due to excess bile acid. Orlistat is an anti-obesity (weight loss) drug that blocks the absorption of fats. This may give side effects of FI, diarrhea, and steatorrhea.

Overflow incontinence
This may occur when there is a large mass of feces in the rectum (fecal loading), which may become hardened (fecal impaction). Liquid stool elements can pass around the obstruction, leading to incontinence. Megarectum (enlarged rectal volume) and rectal hyposensitivity are associated with overflow incontinence. Hospitalized patients and care home residents may develop FI via this mechanism, possibly a result of lack of mobility, reduced alertness, the constipating effect of medication, and/or dehydration.

Pathophysiology

The mechanisms and factors contributing to normal continence are multiple and interrelated. The puborectalis sling, forming the anorectal angle (see diagram), is responsible for the gross continence of solid stool. The IAS is an involuntary muscle, contributing about 55% of the resting anal pressure. Together with the hemorrhoidal vascular cushions, the IAS maintains continence of flatus and liquid during rest. The EAS is a voluntary muscle, that doubles the pressure in the anal canal during contraction, which is possible for a short time. The rectoanal inhibitory reflex (RAIR) is an involuntary IAS relaxation in response to rectal distension, allowing some rectal contents to descend into the anal canal where it is brought into contact with specialized sensory mucosa to detect consistency. The rectoanal excitatory reflex (RAER) is an initial, semi-voluntary contraction of the EAS and puborectalis which in turn prevents incontinence following the RAIR. Other factors include the specialized anti-peristaltic function of the last part of the sigmoid colon, which keeps the rectum empty most of the time, sensation in the lining of the rectum and the anal canal to detect when there is stool present, its consistency and quantity, and the presence of normal rectoanal reflexes and defecation cycle which completely evacuates stool from the rectum and anal canal. Problems affecting any of these mechanisms and factors may be involved in the cause.

Diagnosis
Identification of the exact causes usually begins with a thorough medical history, including detailed questioning about symptoms, bowel habits, diet, medication, and other medical problems. Digital rectal examination is performed to assess resting pressure and voluntary contraction (maximum squeeze) of the sphincter complex and puborectalis. Anal sphincter defects, rectal prolapse, and abnormal perineal descent may be detected. Anorectal physiology tests assess the functioning of the anorectal anatomy. Anorectal manometry records the pressure exerted by the anal sphincters and puborectalis during rest and contraction. The procedure is also able to assess the sensitivity of the anal canal and rectum. Anal electromyography tests for nerve damage, which is often associated with obstetric injury. Pudendal nerve terminal motor latency tests for damage to the pudendal motor nerves. Proctography, also known as defecography, shows how much stool the rectum can hold, how well the rectum holds it, and how well the rectum can evacuate the stool. It will also highlight defects in the structure of the rectum such as internal rectal intussusception. Dynamic pelvic MRI, also called MRI defecography is an alternative that is better for some problems but not as good for other problems. Proctosigmoidoscopy involves the insertion of an endoscope (a long, thin, flexible tube with a camera) into the anal canal, rectum and sigmoid colon. The procedure allows for visualization of the interior of the gut and may detect signs of disease or other problems that could be a cause, such as inflammation, tumors, or scar tissue. Endoanal ultrasound, which some consider the gold standard for detection of anal canal lesions, evaluates the structure of the anal sphincters and may detect occult sphincter tears that otherwise would go unseen.

Functional FI is common. The Rome process published diagnostic criteria for functional FI, which they defined as "recurrent uncontrolled passage of fecal material in an individual with a developmental age of at least four years". The diagnostic criteria are, one or more of the following factors present for the last 3 months: abnormal functioning of normally innervated and structurally intact muscles, minor abnormalities of sphincter structure/innervation (nerve supply), normal or disordered bowel habits, (i.e., fecal retention or diarrhea), and psychological causes. Furthermore, exclusion criteria are given. These are factors that all must be excluded for a diagnosis of functional FI, and are abnormal innervation caused by lesion(s) within the brain (e.g., dementia), spinal cord (at or below T12), or sacral nerve roots, or mixed lesions (e.g., multiple sclerosis), or as part of a generalized peripheral or autonomic neuropathy (e.g., due to diabetes), anal sphincter abnormalities associated with a multisystem disease (e.g., scleroderma), and structural or neurogenic abnormalities that are the major cause.

Definition
There is no globally accepted definition, but fecal incontinence is generally defined as the recurrent inability to voluntarily control the passage of bowel contents through the anal canal and expel it at a socially acceptable location and time, occurring in individuals over the age of four. "Social continence" has been given various precise definitions for the purposes of research; however, generally it refers to symptoms being controlled to an extent that is acceptable to the individual in question, with no significant effect on their life. There is no consensus about the best way to classify FI, and several methods are used.

Symptoms can be directly or indirectly related to the loss of bowel control. The direct (primary) symptom is a lack of control over bowel contents which tends to worsen without treatment. Indirect (secondary) symptoms, which are the result of leakage, include pruritus ani (an intense itching sensation from the anus), perianal dermatitis (irritation and inflammation of the skin around the anus), and urinary tract infections. Due to embarrassment, people may only mention secondary symptoms rather than acknowledge incontinence. Any major underlying cause will produce additional signs and symptoms, such as protrusion of mucosa in external rectal prolapse. Symptoms of fecal leakage (FL) are similar and may occur after defecation. There may be loss of small amounts of brown fluid and staining of the underwear.

Types
FI can be divided into those people who experience a defecation urge before leakage (urge incontinence), and those who experience no sensation before leakage (passive incontinence or soiling). Urge incontinence is characterized by a sudden need to defecate, with little time to reach a toilet. Urge and passive FI may be associated with weakness of the external anal sphincter (EAS) and internal anal sphincter (IAS) respectively. Urgency may also be associated with reduced rectal volume, reduced ability of the rectal walls to distend and accommodate stool, and increased rectal sensitivity.

There is a continuous spectrum of different clinical presentations from incontinence of flatus (gas), through incontinence of mucus or liquid stool, to solids. The term anal incontinence often is used to describe flatus incontinence, however it is also used as a synonym for FI generally. It may occur together with incontinence of liquids or solids, or it may present in isolation. Flatus incontinence may be the first sign of FI. Once continence to flatus is lost, it is rarely restored. Anal incontinence may be equally disabling as the other types. Fecal leakage, fecal soiling and fecal seepage are minor degrees of FI, and describe incontinence of liquid stool, mucus, or very small amounts of solid stool. They cover a spectrum of increasing symptom severity (staining, soiling, seepage, and accidents). Rarely, minor FI in adults may be described as encopresis. Fecal leakage is a related topic to rectal discharge, but this term does not necessarily imply any degree of incontinence. Discharge generally refers to conditions where there is pus or increased mucus production, or anatomical lesions that prevent the anal canal from closing fully, whereas fecal leakage generally concerns disorders of IAS function and functional evacuation disorders which cause a solid fecal mass to be retained in the rectum. Solid stool incontinence may be called complete (or major) incontinence, and anything less as partial (or minor) incontinence (i.e. incontinence of flatus (gas), liquid stool and/or mucus).

In children over the age of four who have been toilet trained, a similar condition is generally termed encopresis (or soiling), which refers to the voluntary or involuntary loss of (usually soft or semi-liquid) stool. The term pseudoincontinence is used when there is FI in children who have anatomical defects (e.g. enlarged sigmoid colon or anal stenosis). Encopresis is a term that is usually applied when there are no such anatomical defects present. The ICD-10 classifies nonorganic encopresis under "behavioural and emotional disorders with onset usually occurring in childhood and adolescence" and organic causes of encopresis along with FI. FI can also be classified according to gender, since the cause in females may be different from males, for example it may develop following radical prostatectomy in males, whereas females may develop FI as an immediate or delayed consequence of damage whilst giving birth. Pelvic anatomy is also different according to gender, with a wider pelvic outlet in females.

Clinical measurement
Several severity scales exist. The Cleveland Clinic (Wexner) fecal incontinence score takes into account five parameters that are scored on a scale from zero (absent) to four (daily) frequency of incontinence to gas, liquid, solid, of need to wear pad, and of lifestyle changes. The Park's incontinence score uses four categories: The fecal incontinence severity index is based on four types of leakage (gas, mucus, liquid stool, solid stool) and five frequencies (once to three times per month, once per week, twice per week, once per day, twice or more per day). Other severity scales include AMS, Pescatori, Williams score, Kirwan, Miller score, Saint Mark's score, and the Vaizey scale.
 * 1) those continent for solid and liquid stool and also for flatus.
 * 2) those continent for solid and liquid stool but incontinent for flatus (with or without urgency).
 * 3) those continent for solid stool but incontinent for liquid stool or flatus.
 * 4) those incontinent to formed stool (complete incontinence).

Differential diagnosis
FI may present with signs similar to rectal discharge (e.g. fistulae, proctitis, or rectal prolapse), pseudoincontinence, encopresis (with no organic cause), and irritable bowel syndrome.

Management
FI is generally treatable with conservative management, surgery, or both. The success of treatment depends upon the exact causes and how easily these are corrected. Treatment choice depends on the cause and severity of the disease, and the motivation and general health of the person affected. Commonly, conservative measures are used together, and if appropriate surgery is carried out. Treatments may be attempted until symptoms are satisfactorily controlled. A treatment algorithm based upon the cause has been proposed, including conservative, non-operative and surgical measures (neosphincter refers to either dynamic graciloplasty or artificial bowel sphincter, lavage refers to retrograde rectal irrigation).

Conservative measures include dietary modification, drug treatment, retrograde anal irrigation, biofeedback retraining anal sphincter exercises. Incontinence products refer to devices such as anal plugs and perineal pads and garments such as diapers/nappies. Perineal pads are efficient and acceptable for only minor incontinence. If all other measures are ineffective removing the entire colon may be an option.

Diet
Dietary modification may be important for successful management. Both diarrhea and constipation can contribute to different cases, so dietary advice must be tailored to address the underlying cause or it may be ineffective or counterproductive. In persons with disease aggravated by diarrhea or those with rectal loading by soft stools, the following suggestions may be beneficial: increase dietary fiber; reduce wholegrain cereals/bread; reduce fruit and vegetables which contain natural laxative compounds (rhubarb, figs, prunes/plums); limit beans, pulses, cabbage and sprouts; reduce spices (especially chili); reduce artificial sweeteners (e.g. sugar-free chewing gum); reduce alcohol (especially stout, beer and ale); reduce lactose if there is some degree of lactase deficiency; and reduce caffeine. Caffeine lowers the resting tone of the anal canal and also causes diarrhea. Excessive doses of vitamin C, magnesium, phosphorus and/or calcium supplements may increase FI. Reducing the olestra fat substitute, which can cause diarrhea, may also help.

Medication
Pharmacological management may include anti-diarrheal/constipating agents and laxatives/stool bulking agents. Stopping or substituting any previous medication that causes diarrhea may be helpful in some (see table). There is no good evidence for the use of any medications, however.

In people who have undergone gallbladder removal, the bile acid sequestrant cholestyramine may help minor degrees of FI. Bulking agents also absorb water, so may be helpful for those with diarrhea. A common side effect is bloating and flatulence. Topical agents to treat and prevent dermatitis may also be used, such as topical antifungals when there is evidence of perianal candidiasis or occasionally mild topical anti-inflammatory medication. Prevention of secondary lesions is carried out by perineal cleansing, moisturization, and the use of a skin protectant.

Other measures
Evacuation aids (suppositories or enemas) e.g. glycerine or bisacodyl suppositories may be prescribed. People may have a poor resting tone of the anal canal, and consequently may not be able to retain an enema, in which case transanal irrigation (retrograde anal irrigation) may be a better option, as this equipment utilizes an inflatable catheter to prevent loss of the irrigation tip and to provide a water tight seal during irrigation. A volume of lukewarm water is gently pumped into the colon via the anus. People can be taught how to perform this treatment in their own homes, but it does require special equipment. If the irrigation is efficient, the stool will not reach the rectum again for up to 48 hours. By regularly emptying the bowel using transanal irrigation, controlled bowel function is often re-established to a high degree in patients with bowel incontinence and/or constipation. This enables control over the time and place of evacuation and the development of a consistent bowel routine. However, persistent leaking of residual irrigation fluid during the day may occur and make this option unhelpful, particularly in persons with obstructed defecation syndrome who may have an incomplete evacuation of any rectal contents. Consequently, the best time to carry out the irrigation is typically in the evening, allowing any residual liquid to be passed the next morning before leaving the home. Complications such as electrolyte imbalance and perforation are rare. The effect of transanal irrigation varies considerably. Some individuals experience complete control of incontinence, and others report little or no benefit. It has been suggested that if appropriate, people be offered home retrograde anal irrigation.

Biofeedback (the use of equipment to record or amplify and then feed back activities of the body) is a commonly used and researched treatment, but the benefits are uncertain. Biofeedback therapy varies in the way it is delivered, but it is unknown if one type has benefits over another.

The role of pelvic floor exercises and anal sphincter exercises in FI is poorly determined. While there may be some benefits they appear less useful than implanted sacral nerve stimulators. These exercises aim to increase the strength of the pelvic floor muscles (mainly levator ani). The anal sphincters are not technically part of the pelvic floor muscle group, but the EAS is a voluntary, striated muscle that therefore can be strengthened in a similar manner. It has not been established whether pelvic floor exercises can be distinguished from anal sphincter exercises in practice by the people doing them. This kind of exercise is more commonly used to treat urinary incontinence, for which there is a sound evidence base for effectiveness. More rarely are they used in FI. The effect of anal sphincter exercises are variously stated as an increase in the strength, speed, or endurance of voluntary contraction (EAS).

Electrical stimulation can also be applied to the anal sphincters and pelvic floor muscles, inducing muscle contraction without traditional exercises (similar to transcutaneous electrical nerve stimulation, TENS). The evidence supporting its use is limited, and any benefit is tentative. In light of the above, intra-anal electrical stimulation (using an anal probe as an electrode) appears to be more efficacious than intra-vaginal (using a vaginal probe as an electrode). Rarely, skin reactions may occur where the electrodes are placed, but these issues typically resolve when the stimulation is stopped. Surgically implanted sacral nerve stimulation may be more effective than exercises, and electrical stimulation and biofeedback may be more effective than exercises or electrical stimulation by themselves. TENS is also sometimes used to treat FI by transcutaneous tibial nerve stimulation.

In a minority of people, anal plugs may be useful for either standalone therapy or in concert with other treatments. Anal plugs (sometimes termed tampons) aim to block the involuntary loss of fecal material, and they vary in design and composition. Polyurethane plugs were reported to perform better than those made of polyvinyl-alcohol. Plugs are less likely to help those with frequent bowel movements, and many find them difficult to tolerate.

In women, a device that functions as an inflatable balloon in the vagina has been approved for use in the United States.

Surgery
Surgery may be carried out if conservative measures alone are not sufficient to control incontinence. There are many surgical options, and their relative effectiveness is debated due to a lack of good-quality evidence. The optimal treatment regime may be both surgical and non-surgical treatments. The surgical options can be considered in four categories: restoration and improvement of residual sphincter function (sphincteroplasty, sacral nerve stimulation, tibial nerve stimulation, correction of anorectal deformity), replacement/imitation of the sphincter or its function (anal encirclement, SECCA procedure, non-dynamic graciloplasty, perianal injectable bulking agents), dynamic sphincter replacement (artificial bowel sphincter, dynamic graciloplasty), antegrade continence enema (Malone procedure), and finally fecal diversion (e.g. colostomy). A surgical treatment algorithm has been proposed. Isolated sphincter defects (IAS/EAS) may be initially treated with sphincteroplasty and if this fails, the person can be assessed for sacral nerve stimulation. Functional deficits of the EAS and/or IAS (i.e. where there is no structural defect, or only limited EAS structural defect, or with neurogenic incontinence) may be assessed for sacral nerve stimulation. If this fails, neosphincter with either dynamic graciloplasty or artificial anal sphincter may be indicated. Substantial muscular and/or neural defects may be treated with neosphincter initially.

Epidemiology
FI is thought to be very common, but much under-reported due to embarrassment. One study reported a prevalence of 2.2% in the general population. It affects people of all ages but is more common in older adults (but it should not be considered a normal part of aging). Females are more likely to develop it than males (63% of those with FI over 30 may be female). In 2014, the National Center for Health Statistics reported that one out of every six seniors in the U.S. who lived in their own homes or apartment had FI. Men and women were equally affected. 45–50% of people with FI have severe physical and/or mental disabilities. People with dementia are four times more likely to have fecal incontinence compared to people of similar ages.

Risk factors include age, female gender, urinary incontinence, history of vaginal delivery (non-Caesarean section childbirth), obesity, prior anorectal surgery, poor general health, and physical limitations. Combined urinary and fecal incontinence is sometimes termed double incontinence, and it is more likely to be present in those with urinary incontinence.

Traditionally, FI was thought to be an insignificant complication of surgery, but it is now known that a variety of different procedures are associated with this possible complication, and sometimes at high levels. Examples are midline internal sphincterotomy (8% risk), lateral internal sphincterotomy, fistulectomy, fistulotomy (18–52%), hemorrhoidectomy (33%), ileo-anal reservoir reconstruction, lower anterior resection, total abdominal colectomy, ureterosigmoidostomy, and anal dilation (Lord's procedure, 0-50%). Some authors consider obstetric trauma to be the most common cause.

History
While the first mention of urinary incontinence occurs in 1500 BC in the Ebers Papyrus, the first mention of FI in a medical context is unknown. For many centuries, colonic irrigation was the only treatment available. Stoma creation was described in AD 1776, FI associated with rectal prolapse in AD 1873 and anterior sphincter repair in AD 1875. During the mid 20th century, several operations were developed for instances where the sphincters were intact but weakened. Muscle transpositions using the gluteus maximus or the gracilis were devised, but did not become used widely until later. End-to-end sphincteroplasty is shown to have a high failure rate in 1940. In AD 1971, Parks and McPartlin first describe an overlapping sphincteroplasty procedure. Biofeedback is first introduced in 1974. In 1975, Parks describes post anal repair, a technique to reinforce the pelvic floor and EAS to treat idiopathic cases. Endoanal ultrasound is invented in 1991, which starts to demonstrate the high number of occult sphincter tears following vaginal deliveries. In 1994, the use of an endoanal coil during pelvic MRI shows greater detail of the anal canal than previously. During the last 20 years, dynamic graciliplasty, sacral nerve stimulation, injectable perianal bulking agents and radiofrequency ablation have been devised, mainly due to the relatively poor success rates and high morbidity associated with the earlier procedures.

Society and culture
Persons with this symptom are frequently ridiculed and ostracized in public. It has been described as one of the most psychologically and socially debilitating conditions in an otherwise healthy individual. In older people, it is one of the most common reasons for admission into a care home. Persons who develop FI earlier in life are less likely to marry and obtain employment. Often, people will go to great lengths to keep their condition secret. It has been termed "the silent affliction" since many do not discuss the problem with their close family, employers, or clinicians. They may be subject to gossip, hostility, and other forms of social exclusion. The economic cost has not received much attention.

Netherlands
In the Netherlands, a 2004 study estimated that total costs of patients with fecal incontinence were €2169 per patient per year. Over half of this was productivity loss in work.

United States
In the US, the average lifetime cost (treatment and follow-up) was $17,166 per person in 1996. The average hospital charge for sphincteroplasty was $8555 per procedure. Overall, in the US, the total charges associated with surgery increased from $34 million in 1998 to $57.5 million in 2003. Sacral nerve stimulation, dynamic graciloplasty, and colostomy were all shown to be cost-effective.

Japan
Some insults in Japan relate to incontinence, such as kusotare/kusottare and shikkotare which mean shit hanger/leaker/oozer and piss leaker/oozer respectively, though these have not been in common use since the 1980s.

Law
The case Hiltibran et al v. Levy et al in the United States District Court for the Western District of Missouri resulted in that court issuing an order in 2011. That order requires incontinence briefs funded by Medicaid to be given by the State of Missouri to adults who would be institutionalized without them.

Research
Engineered anal sphincters grown from stem cells have been successfully implanted in mice. New blood vessels developed and the tissue displayed normal contraction and relaxation. In the future, these methods may become part of the management of FI, replacing the need for high-morbidity implanted devices such as the artificial bowel sphincter.

title: Fecal incontinence


text:
Incontinence

Incontinence or Incontinent may refer to:

 * Urinary incontinence, the most commonly occurring type of incontinence, the involuntary excretion of urine
 * Fecal incontinence, the involuntary excretion of bowel contents
 * Lack of moderation or self-control, especially related to sexual desire - see Incontinence (philosophy)
 * Incontinent (album), a 1981 album by Fad Gadget

title: Incontinence


text:
Schlei

The Schlei (Slien or Slesvig Fjord ) is a narrow inlet of the Baltic Sea in Schleswig-Holstein in northern Germany. It stretches for approximately 20 miles (32 kilometers) from the Baltic near Kappeln and Arnis to the city of Schleswig. Along the Schlei are many small bays and swamps. It separates the Angeln peninsula to the north from the Schwansen peninsula to the south.

The important Viking settlement of Hedeby was located at the head of the firth (fjord), but was later abandoned in favor of the city of Schleswig. A museum has been built on the site, telling the story of the abandoned town.

title: Schlei