Constipation

Constipation is a very frequent accompaniment of digestive disturbances, and while it is usually only a symptom in itself, and disappears as the trouble which caused it is cured, it deserves separate consideration.

It is my impression that a great deal of constipation, or irregularity of the stools, is due to the fact that many people do not know how to attend to the important function of defecation. They either do not understand it, or they wilfully neglect it.

A little study of the parts involved, and their physiological action will be interesting and instructive.

Food, after passing through the small intestine rather rapidly, enters the colon, or large intestine, as a liquid, or of a liquid consistency. The fluid is largely absorbed during the slower passage through the large intestine, leaving a residue of faeces to be discharged from the rectum.

The large intestine is about five feet long, including the rectum, which comprises the last eight inches. The rectum, like the rest of the intestinal canal, has involuntary muscles in its walls, running both longitudinally and circularly. The circular muscular fibres near the outlet are increased in thickness and form a well defined ring, about one inch wide, called the internal sphincter muscle. Just beyond this, but entirely separate from it, is the external sphincter, of voluntary fibres, which ordinarily keeps the anus closed.

Now notice the different kind of muscles composing the internal and external sphincters. The external sphincter is a sort of purse-string muscle, under control of the will, which keeps the outlet closed except when we wish to discharge the contents of the rectum. The internal sphincter, is, like all the rest of the muscular fibres in the intestinal wall, an involuntary muscle, and we cannot directly compel it to open or shut by will power, no matter how much we may desire it.

The contents of the intestinal canal are propelled onward by peristaltic, or worm-like movements, which are entirely involuntary.

These movements are caused by wave-like contractions of the muscles in the walls of the tubes, each part of the tube as the wave reaches it, narrowing its calibre, and then gradually relaxing and dilating. This wave of contraction is gentle, and progresses slowly from above downward. The advancing wave is always preceded by a wave of relaxation, or inhibition. When we inhibit or relax the tension of the muscular fibres in any circular organ, as intestine or blood vessel, the organ naturally dilates and the space in its centre becomes larger.

As the contents of the large intestine arrive at the rectum they are composed of undigested and indigestible matter, about 75 per cent of water, and considerable waste matter, including cast-off cells, inorganic salts, putrid products, and bacteria. When a sufficient quantity of faeces has arrived in the rectum there is felt a need of expelling it. This sensation varies greatly, according to the amount of matter present, and the susceptibility of the individual, but principally owing to the nature of the discharge. If the matter is rather solid, and of a non-irritating nature, it may be retained in the rectum for hours, or even days, while if it be watery or acrid, as in diarrhoea, the strongest effort of the will is sometimes insufficient to keep the external sphincter closed and prevent a passage of the contents.

The act of defecation is normally an involuntary one, as may be seen in infants and animals on a natural diet. In most adults it becomes partly voluntary, owing to a variety of causes, such as the habit of preventing the stool until a convenient time, and to unhygienic habits in general. The voluntary part is, however, small than generally supposed, consisting mainly in the relaxation of the outlet, and the compression of the abdominal contents by holding the breath and contracting the diaphragm and abdominal muscles.

The compression of the abdomen, or straining, practiced by many persons, and particularly constipated people, usually does more harm than good. It has no effect on matter in the lower part of the rectum, as Professor Foster says in his Textbook of Physiology” A body introduced per anum into the empty rectum is not affected by even forcible contractions of the abdominal walls.”

If the peristaltic movement is not operating in the rectum, and the internal sphincter is not properly relaxed, we should not try to have a movement. If, under these unfavourable circumstances, after long straining, we do succeed in our object, what happens is about as follows: We have so compressed the abdominal portion of the large intestine that its contents, perhaps unready for the movement, are squeezed downward, while the absorption of the fluid portion is unnaturally hastened, and matter thrown into the blood that should have been further elaborated in the bowel, or discharged with the faeces.

Although a passage may sometimes be affected by such unnatural straining, its results, both immediate and remote, are bad. The immediate effect includes the disarrangement of the digestive processes, not only in the large intestine, but in the small as well, and probably other abdominal organs, in the forcible pushing into the blood and lymphatic circulations of unsuitable substances, causing headaches and auto-intoxification, while the after consequences are that the constipated habit is more firmly fixed, the next stool almost certainly being dry and hard, and the natural mechanism of defecation more weakened and less inclined to perform its duty.

Piles, or haemorrhoids, are probably always caused by straining at stool, as the pressure prevents the venous blood returning to the heart and it accumulates in the mucous membrane of the rectum and distends it until tissue gives way and a blood tumour, or pile, results.

The contents of the bowel act in different ways to produce a normal stool. By irritating the mucous membrane, nervous centres are excited which cause a reflex peristaltic movement of the intestinal muscles, and by the secretion, or production of osmotic conditions, which cause fluid to flow into the cavity of the intestine, until it becomes so watery that it may be discharged.

Various laxative foods act directly, on the arrival of their undigested portions at the rectum, as the coarse fibres of cereal coverings, small seeds of fruit, or indigestible skins of tomatoes, prunes, etc., or they may act immediately through the circulation, as it is not uncommon for people to have to go to stool within a short time after eating the first peach, or pear of the season, or any fruit that is unusually well relished. And some people say that eating an article which causes a copious flow of saliva will bring on a movement. A small amount of laxative fruit usually acts better than too large a quantity. Some doctors advise the eating of just one fig at bedtime, or one apple before breakfast, knowing that eating a larger amount, or perhaps over-eating, seems to have frequently opposite of a laxative effect. Overeating of any food or foods is a prolific source of constipation.

While constipation is an unsanitary habit, to say the least, it is nevertheless a fact that many people who have it magnify the condition and its dangers. There are many such persons, whose one object in life seems to be the have a daily movement, whether there is anything to be moved or not, and they are in misery unless they have it. And, after having it, by force, if necessary, they are not happy, because they immediately begin to plan for the next day. Everything they eat or drink is judged by the test: Is it constipating, or not? They stuff themselves with unsuitable foods, because some one declares them laxative, and they decline really nutritious articles, because they may have a reputation for causing costiveness. Their drinks, also, have to pass the same test, and healthful fluids are rejected, perhaps in favour of some foul smelling and tasting mineral water, because the latter moves their bowels, disregarding the fact that these waters are often artificially impregnated with salts by the manufacturers and may contain many impurities. It is but a step from them to out-and-out cathartic medicines, and then, usually, all chance of restoring the normal movements of the bowels is gone, except by radical action.

A simple and good cure for many of these cases, which I have often successfully applied, where the people had common sense and will power enough to carry it out, is to have them eat, in moderation, everything they relish, chewing it well, and instead of trying to have a movement of the bowels, try hard not to have one. Instead of yielding to the first faint hint that the bowels might move, restrain it, until the next day, or two or three days, if necessary. Retain even the gas, if any is inclined to pass, and, my word for it, there will come a time when an impulse will be felt about which there can be no mistake, and a satisfactory evacuation will result, without straining or forcing into the circulation a lot of stuff which does not belong there. Don’t try to force out every particle that you think may be in the rectum, but keep some for next time, so to speak, and the next time will also be easy, and the next time after that, and all the other times. This plan will not suit the manufacturers of expensive machines intended to wash all the food out of the colon, by using large hot-water injections. They may claim that you will get ptomaine poisoning, or auto-intoxification, but such things, in my experience, have usually been caused by bad food, imperfectly digested, forced out of the colon into the body against the wishes of the absorptive cells, which could not stand the pressure put on them.

As to the use of injections, I will say here, that occasions may arise when they are temporarily of great use, but as a means of curing constipation, it is irrational to distend the bowel, already weakened and dilated, with large enemas of warm, or hot water, and the most difficult cases to cure are those where the colon and rectum are paralyzed from long use of such measures.

There would be very little constipation with any one, if the internal sphincter relaxed readily. While it is contracted it acts very much like a valve or gate, opening inwardly, and the more pressure we put on it the tighter it is shut.

Just why it does not open, or relax, when we wish it to, is a difficult question to answer. It cannot be relaxed by simply willing it to as we would relax the muscles of the arm, for it is not a voluntary muscle. Some people, who are always on a nervous tension, put so much extra force on the external sphincter all the time that it gets in a state of continuous or tonic contraction, and communicates its rigidity to the internal muscle sympathetically. Such people may suddenly decide that it is time to have a movement, and they relax the outer muscle, and attempt, by pressure, to overcome the resistance of the inner muscle. But this is not the right way to go at it.

A better way is outlined above; simply wait until the desire is irresistible; then the inner sphincter is sure to be relaxed and the peristaltic movement sufficient to move the content out without using abdominal pressure.

Another, and perhaps, opposite method of securing the desired result is to obtain a general relaxation of the body, which will secondarily or sympathetically affect the involuntary muscles. This is explained in another part, under the title of Rest.

A method frequently advised is the use of massage over the abdomen, by manipulation with the hands, or rolling a cannon ball over the location of the colon, or bringing the abdomen forcibly against some object, as a strap between two posts. All these are unnatural procedures, and while possibly useful, temporarily, in some cases, they never tend to produce a cure, but instead, further weaken the intestinal muscles by usurping their functions.

As contrasted with passive exercise, active exercise is far better. Exercise of any part of the body makes deeper breathing necessary, and that means more up and down action of the diaphragm, which in turn produces more movements of the abdominal contents. More oxygen enters the blood, and more blood circulates through the vessel everywhere, stimulating all the muscles. This induces warmth, and perspiration, and when there is external perspiration, there is usually a watery excretion through the mucous membrane of the intestines as well, for the inner lining of the intestines is really outside of the body proper, in the same way that the skin is.

Not only does proper exercise bring into use the external muscles of the abdomen, whose action is readily apparent, but also important muscles lining the abdominal cavity, connecting the backbone and pelvis and thighs, the movements of which must have a considerable influence on the abdominal viscera.

There can be no question about the benefits of exercise to the constipated, it is a necessity. Movements particularly useful in these cases will be explained under Exercise. Some directions in regard to diet will be given in the chapter entitled After Treatment.

The reader will note that so far, in treating of constipation, I am speaking of persons in ordinary circumstances, and not those on the milk diet, or resting.

What does the milk diet do for people afflicted with constipation? It is the only perfect and natural cure that I know of.

On no other diet can the bowels be restored to the natural functions, while the patient remains in bed, resting.

On no other possible diet can any one build up the entire muscular system of the body, both voluntary and involuntary, while taking complete rest.

On no other diet is it possible for one to gain healthy flesh rapidly, without exercising, or submitting to massage.

Most people find that drinking fresh milk with other food increases the tendency to constipation. Even when they attempt an exclusive milk diet, using a few pints daily, the trouble is increased. A few people of this class say that milk acts as a laxative to them, and the use of buttermilk, sour milk, and sour milk cheese, tends to prevent constipation in nearly every case.

It is impossible to use anything but fresh milk in the milk cure, because that is the only substance that the stomach can take continuously, for unlimited periods, without tiring of or rejecting. However, it is often useful to give a glass or two of buttermilk, or some cottage cheese (made without cooking) if the bowels do not move naturally while taking the full amount of milk. Sour milk that has coagulated, called “clabber,” or “loppered milk,” may be beaten up with an egg-beater, and makes a very good substitute for buttermilk.

But the best of all ways of overcoming the initial constipation on a milk diet is to take more milk. In every case there is necessarily a considerable portion of the milk undigested, and the percentage of undigested matter increases as we increase the amount taken. On a generous milk diet regular stools occur largely as a mechanical result at first: the accumulated faeces are too great in amount to be retained. This is often noticed where patients are taking an amount of milk somewhat too small to cause daily movements. Increasing the amount one or two pints daily generally has an immediate effect, changing the discharge from dry, hard, round balls to a soft, continuous cylinder, with more frequent movements. It is possible that only a small portion of the additional milk is digested, although an increased rate of gain in weight is always shown in such cases.

While it is true that certain parts of the milk, as the fat and casein, or cheese, are never entirely digested, there are other parts, as albumin, milk sugar, and mineral salts that are completely assimilated. The cells lining the alimentary canal have a selective action: they take out what is needed, and reject the remainder, and, under the natural conditions surrounding the milk cure, it is always better to provide too much food than too little, in order to be sure of getting enough of the absolutely necessary materials. Where only one kind of food is taken, it is a simple matter for the digestive apparatus to select from it the needed ingredients, and pass on the residue. The dream of theorists that some day we may be able to supply all the needs of the body by means of a daily pill and a swallow of liquid, and not have any undigested residue to bother with, will never come true.

Before starting the milk diet, constipated persons should have at least 36 hours fast from ordinary foods, but any ripe, fresh, or dried fruits (except bananas) may be eaten. If the stomach is too weak to handle raw fruits, they may be cooked, without using sugar. Several glasses of water, either hot or cold, should be taken, but do not distend the stomach with it too much, for water, taken in unusual quantities, is almost as indigestible and uncomfortable as some foods are, to a weak stomach. It is not absolutely necessary to have fruit during the fast, and if patients cannot find fruit that they can eat with a relish, they had better omit it. But where fruit is eaten, it is frequently the case that, on beginning the milk diet, the bowels move spontaneously the first day. If the bowels do not move the first day, let them go until the next morning, unless positive discomfort is experienced, and, if no indications of a movement on the second day, an enema of warm water (at the body temperature) may be taken. No more water should be taken than is necessary to accomplish the purpose, and, if even a small passage is secured, do nothing more until the next morning, unless the bowels move naturally. Do not strain, or attempt to force a movement.

The movement on the morning of the second day of milk drinking will contain the undigested part of the fruit eaten just before starting the milk, and perhaps the last part of it will be tinged white or yellow by the milk. The movement on the third morning may still contain traces of the fruit, but will be mostly a milk stool.

If any trouble is experienced in passing faeces from the rectum, even with the aid of an enema, it will be on this third morning, and never after that. It is only a local trouble, right at the outlet of the rectum, and copious injections of warm water, with perhaps a little soapsuds or castor oil, will overcome it, and it will not recur, if the milk is kept going regularly.

It is best to secure an evacuation every day, if only a small one, and the warm water enema will be all that is necessary to obtain it. If the injection is needed for several days, decrease the amount of water used every day, until only about a teacupful is used. The rectum will be getting more power all the time, and probably the faeces will become softer.

After about a week of using the warm water injections without securing spontaneous movements, it is a good plan to use a very small injection of cold water, the colder the better. Cold water acts as a stimulant to the rectal muscles and causes a contraction which brings on the movement. Usually two or three trials with cold water will put the bowels in shape to have natural movements.

The colour of the stools, after the bowels are clear of food previously eaten, is a chalky, or grayish white, in nearly every case. A few persons have soft stools, of a yellowish colour, right from the start. As the patient goes on with the diet, more yellow colour appears, and the discharge is softer, and movements more frequent—two or three a day. A light orange colour usually indicates a good condition of the bowels.

When normal evacuations are established, there is never any return to a constipated condition so long as the same conditions of rest, milk, etc., are continued. When ordinary diet and habits are resumed there is very seldom any difficulty, because the regular habits established while on the milk, and the increased power of peristaltic muscles, the improved digestion, and increased circulation, all tend to prevent a relapse.

There have been patients with obstinate and long-continued constipation, who, for lack of time, could not stick to the milk diet long enough to entirely overcome their trouble, but who found their movements entirely regular on resuming ordinary diet.

Of all the constipated people who have taken the treatment correctly, for at least four weeks, at least 98 per cent have been completely and permanently cured