Causes

Constipation, like diarrhea, may either be a symptom of disease or in many cases constitute of itself the complete morbid condition. Infrequent and small bowel movements are the phenomena of constipation. Mechanical obstruction within the bowel, or compression from without are sometimes causes of it. They constitute varieties of constipation requiring special treatment. Dietetic treatment may be of use in the beginning of these cases. Constipation is also caused by dietetic faults. Food may be insufficient in quantity or too concentrated; too little fluid may be drunk, or foods or drinks may be taken that are astringent and indigestible. It is rare that too much food taken at one time is the cause of obstructive constipation. More frequently it is due to a diminution of intestinal secretions and weakness of the intestinal muscles. Paresis of the bowels from spinal or cerebral disease sometimes prevents normal and regular defecation. In certain cases constipation is caused or aggravated by spastic contraction of the lower part of the colon. Worry and depression are frequent causes of this condition. In other cases that portion of the intestine is so sensitive as to be stimulated to contract by its usual contents. Many of these causes of constipation are removable.

Chronic constipation leads to numerous complications. Among the commonest are sacral neuralgia and hemorrhoids. When feces become impacted or persistently lodged at one point, they often excite local inflammation and temporary-diarrhea. In such cases from two to four days of constipation alternate with one or two of diarrhea. When impaction of feces lasts long, local pain and tenderness and sometimes fever will occur. Mental irritability, inability to concentrate the mind and to think clearly, lack of energy and ambition, are symptoms commonly associated with constipation. Headache and left-sided pleurodynia are also frequent accompaniments of it.

Treatment

In the treatment of this condition it is especially necessary to inquire carefully as to the habits of the patient, both in order to learn of possible causative conditions and to ascertain dietetic idiosyncrasies, if he has any.

Nothing helps more to prevent constipation than regular habits of eating and of attempting defecation. The bowels should be moved each morning at a regular time. A habit may be thus acquired that is invaluable for the preservation of health. Mental worry and harassment should be avoided, for depressing mental states check peristalsis. A sedentary life is the commonest cause of constipation. It induces shallow respiration, lessened difference in intrathoracic pressure, and, therefore, less aspiration of lymph and venous blood into the thorax, which results in an imperfect removal of waste-products from the tissues of the abdominal organs. Lack of exercise also weakens the intestinal and abdominal muscles, and by preventing thirst, lessens the amount of water drunk and, consequently, diminishes intestinal secretions. It is not to be wondered at that those who lead a sedentary life are especially liable to constipation. To correct this condition enough exercise, preferably active exercise, must be taken to restore tone to voluntary muscles, to provoke deep breathing, and to force the use of the abdominal and other body muscles. Stooping, bending, flexing the thighs against the body, and slow, deep breathing are especially useful exercises. Massage may be used as a substitute for active exercise and is often at first preferable to it in stubborn cases. Massage, while general, should be applied especially to the abdomen. Hydrotherapy is useful. Cold, wet packs and a cold spray upon the abdomen are the best forms of its application. Both massage and cold packs are more harmful than useful when spastic contraction of the colon causes constipation. Often in such cases hot applications to the abdomen and hot enemeta do good.

Enemeta of olive oil given each night for two or three weeks and then for the same period every second night and for a third period at gradually longer intervals is very efficient in overcoming chronic constipation. From four to six ounces or from one-half to a whole cupful of oil is given at a time. It should be about body temperature and introduced into the bowel slowly and as high up as possible. It should be retained all night. Some of the oil is absorbed but much of it comes away with the stool in the morning. Its laxative effect is doubtless a local one and not due to its absorption.

Occasionally individuals are met who have idiosyncrasies that cause or relieve constipation. As a rule, mental depression will provoke constipation, while mental excitement, particularly if the element of fear enters into the case, will sometimes produce diarrhea. Milk oftener produces constipation than diarrhea, but there are those who are physicked by it. Certain vegetables and fruits always have a pronounced laxative influence upon some individuals, and more or less upon most persons. When they exist, these dietetic peculiarities are important guides to treatment.

Diet

In order to produce peristalsis it is essential that the intestines contain a certain bulk of fecal matter. A diet rich in meat and eggs, and the sparing use of vegetables, fruits, and water will produce a small residue of undigested matter. Therefore the intestines will fill very slowly to a point sufficient to provoke vigorous peristalsis. When such a diet is habitual to a patient, it should be changed. Vegetables, fruits, coarse breads, and water should be taken freely. These foods should contain a large amount of cellulose, which remains undigested, fills the intestine, and excites in it peristaltic activity.

The vegetables that are most laxative are tomatoes, spinach, lettuce, asparagus, Spanish onions, salsify, cabbage, and celery.

Spinach and tomatoes are especially prized for their effect upon the bowels. The coarse cereals have the same reputation. Oatmeal, cornmeal, and wheaten grits are the best. Bread made of coarse flour, such as Graham, rye, corn, oats, and 'whole wheat' meal, also helps to prevent and to relieve constipation. Bran bread is especially efficacious. It is made by adding bran to ordinary flour or to graham flour in as large a proportion as is compatible with the making of good bread. Such breads as ginger-bread and Boston brown bread are also laxative, but often cannot be used because they provoke gastric indigestion. Agar-agar, a native of Japan, also produces the bulky stools which are needed. It is best given as a powder or mixed with a breakfast food. Two to four teaspoonfuls are given commonly each day and much more than this can be taken if it is needed. It is not digested or absorbed to an appreciable extent but helps to make a large stool, because it swells in the liquid contents of the intestine. It is the essential ingredient of several proprietary laxatives.

Honey, molasses, and food eaten with them are also reputed useful for the relief of constipation. One patient of mine who had been afflicted with chronic constipation for years was able to keep his bowels in good order for months at a time by eating a home-made candy made of lard and molasses. Honey has been used in all ages as a mild laxative.

Many persons are sensible of the stimulation of peristalsis that coffee produces. The addition to it of much sugar and cream will sometimes retard gastric digestion and may thus counteract its stimulating effect upon the bowel.

Fruits have a laxative influence, partly because of the sugar that they contain, partly because of the fruit acids, and sometimes because of their irritating skins and seeds. Berries - strawberries, blackberries, raspberries, blueberries, gooseberries, - currants, and grapes are effective partly because of their seeds and partly because of the acids that they contain or that are generated during digestion. Apples, pears, peaches, plums, cherries, oranges, and grape-fruit are chiefly purgative because of their sugar and fruit acids. Prunes, figs, raisins, and dates have, besides these, either a skin, or seeds that act as local irritants in the intestines.

Fruit produces the greatest laxative effect when eaten alone. It is, therefore, best taken at bedtime and on rising, a half-hour or, better, an hour before breakfast. A compote with meals will do good, although it is not so effective as fruit taken upon an empty stomach. Apple-butter, date-butter, marmalades, and similar preparations are often eaten upon bread or crackers. A mild but serviceable fruit laxative can be made by cooking together equal weights of dried dates, prunes and apricots until they are reduced to pulp. The skins must be removed by passing the mixture through a coarse sieve. It can be eaten freely alone or spread upon bread. It is agreeable and particularly useful for constipated children.

Many who are constipated fail to drink enough fluids either to keep the contents of the intestines soft or to form intestinal secretions as abundantly as is needful. This is especially true of those who lead a sedentary life, and of women. If, upon inquiry, it is found that enough water is not habitually taken, more must be prescribed. Slight constipation may often be relieved by a glass of cold water the first thing in the morning. The laxative effect is enhanced if another is taken at bedtime. The morning draft stimulates peristalsis and secretion. Under its influence the rectum is slowly filled, and a half-hour or an hour later, breakfast provokes the desire to defecate. The habitual use of hard water is constipating unless magnesium and sodium sulphates occur with the lime-salts in sufficient quantities to make it laxative. Distilled water or soft water has a neutral action. Water containing much organic matter frequently provokes diarrhea. An average-sized man should drink from five to eight glasses daily.

Sweet cider is loosening to the bowels. Grape-juice, if taken freely, acts similarly. Tea is an astringent, especially when made by boiling or prolonged leaching of the leaves. Tea drinking is not an uncommon cause of constipation.

Only the mild cases of constipation can be relieved by dietetic and hygienic measures alone; but proper habits of eating, drinking, and living are essential to a perfect cure in any case. This is not the place to consider the value of electricity, massage, and the various laxative drugs, but their help is often necessary.

Nurslings are at times constipated. The proportion of fats and proteins in their mothers' milk is frequently abnormal. This may be changed by suitable treatment of the mother. (See Part 1, Chapter xi (Infant Feeding. Mother'S Milk).) Indigestion and constipation many times coexist in mother and babe. When the mother is relieved, the child often recovers.

Frequently infants can be helped by giving them water to drink. When stools are hard and dry, water is needed. In other cases a few drops or a whole teaspoonful of olive oil, cod-liver oil, syrup, or malt or a little butter will relieve constipation.

Oatmeal water is used as a laxative for infants. Condensed milk and 'prepared' foods are usually laxative. Massage, ene-mata of water, or water with a little salt, soap, or glycerin, or a glycerin or soap suppository must be employed in the most intractable cases. Sometimes calomel, castor oil, and other drugs must also be used.

Children who are more than two and one-half years old and no longer upon an exclusive milk diet must be treated upon the same principles as adults.