Treatment Of Cumulative Constipation

In the treatment of cumulative constipation it is to be borne in mind that the principal obstacle to bowel movement is the undue accumulation of fecal matters either in the pelvic colon or the rectum, or as is most often the case, in both the pelvic colon and the rectum. In many cases the food is carried from the stomach to the colon with a proper degree of rapidity, and the feces move at the normal rate through the colon, until they have passed the splenic flexure. At this point the delay begins. In time, through extraordinary neglect, when the feces are allowed to accumulate for days and even weeks in succession, the colon and even the small intestine may become enlarged through the obstruction at the outlet.

The chief cause of cumulative constipation, in ordinary cases, as has already been pointed out, is neglect to attend to the "call" of Nature for the evacuation of the bowels. When the "call" occurs, it is because the rectum is distended with feces.

If the defecating mechanism then is interrputed in its action, and its purpose thwarted many times, the "call" becomes residuary, and the effort to defecate is so slight that it is easily suppressed. Later, in the worst cases, the desire to evacuate the bowels entirely disappears. In these cases the sensibility of the rectum has become blunted to such a degree that the normal reflex is lost. The rectum tolerates the presence of feces without protest and without giving any signal to the defecating center that bowel movement is required.

It is evident, then, that in the treatment of cases of cumulative constipation the first and most essential thing is restoration of the normal sensibility of the rectum. It must be remembered, however.

that in most cases of cumulative constipation, as well as in other forms of constipation, the condition has existed for a long time. The disease has consequently extended to the entire colon, and perhaps to the entire intestine, and success will not be obtained by attention to the colon and rectum alone; consequently, the treatment of cumulative constipation requires the use of all the measures which have been recommended for simple constipation, the description of which need not be repeated here.

The first thing to be done, in beginning the treatment of cumulative constipation is to thoroughly evacuate the lower bowel and rectum. This is best accomplished by the use of the enema. It is certainly irrational to administer a laxative or cathartic, which disturbs the alimentary canal through its whole length, for the purpose of removing an obstructive accumulation which perhaps lies within six inches of the lower outlet.

A simple water enema at a temperature of 104° to 110° should be given to soften the hardened feces, and should be repeated at intervals of half an hour, until the colon is completely emptied, as shown by the return of clear water. The addition of soap to the water sometimes hastens the softening of very hard fecal matter. Warm oil has been much recommended, but it dissolves hard feces less rapidly than water. At first it may be impossible to introduce more than a small quantity of water, on account of the extreme distention of the rectum and pelvic colon with feces. By a persevering effort, however, success will be attained; as the hard feces are gradually softened and dissolved, larger quantities of water may be introduced until the whole colon may be filled with water and emptied of its putrefying contents. In cases in which the fecal accumulation has been going on for several weeks, the patient must be put in charge of an experienced nurse, whose efforts under careful instruction, must be unremitting until the task is completely accomplished. When the feces are very hard, and the masses of considerable size, oil should be used at intervals to lubricate the walls of the bowels, which, in such cases, are often dry and sometimes roughened.

After the bowels have been first thoroughly emptied, infinite care must be taken to see that another accumulation never occurs. Every time the bowel is distended by fecal accumulation, its muscles are weakened, the sensibility of its nerves diminished, and any improvement which may have been secured by previous treatment is lost. By the systematic use of the enema, the bowel being kept empty, gradually contracts and returns to something like its normal proportions.

The cold enema should always be used for contracting the bowel after the fecal matters have been removed by a warm enema. When once the bowel has been thoroughly emptied, warm water may no longer be required, and it will not be necessary to resort to the use of the hot enema. The temperature of the water ordinarily used for the evacuation of the bowels may then be about 80°. After a little training, a lower temperature may readily be tolerated and is greatly preferable. When very cold water is used, the effect is sometimes to produce a spasm of the anus, so that the contraction of the muscles prevents proper movement. When this occurs, the anus may be relaxed by the application of a sponge or napkin saturated with very hot water, or water of a higher temperature may be used for the enema.

The best time for administering the enema is in the morning, after breakfast; but if circumstances will not permit this, the bowels may be moved at night after supper, or just before retiring. With patients who suffer from hemorrhoids or painful ulcers of the rectum, the hour of retiring is the best time for moving the bowels by an enema, as afterward there may be prolonged rest on the back. This prevents the extrusion of swollen hemorrhoids or prolapsing rectum, and gives rest to the anal muscles, and so prevents the nagging, painful contractions which often follow bowel movement when fistulae or ulcers are present.