Constipation.
Synonym:—Costiveness.
Definition:—Constipation is a condition in which there is deficient peristaltic action of the intestinal muscular structure, and as a result there is fecal retention, or deficient evacuation of the bowels. It is not a disease in and of itself; it is but a symptom present in many diseases. Nevertheless it should be considered by itself, as in so many cases it is the chief symptom, the condition from which other manifestations of physical disorder result, and which disappear when the constipation is corrected. It may be considered in both an acute and chronic form.
Acute Constipation:—The causes only of acute constipation need to be mentioned here, as they are discussed under the heads of diseases in which this condition is a marked symptom. The most serious of these causes is intestinal obstruction. The condition is also present usually in some forms of appendicitis and in peritonitis, because of the paresis of the musculature of the intestines which results from that condition. It is found also in fevers, in which diarrhea is not a part of the disease underlying the fever, and because in febrile states all glandular action, and especially that of the intestinal tract, is inhibited.
Chronic Constipation:—The causes of chronic constipation are mainly as follows: (a) Heredity. Constipation is often a family habit, and is observed in brunettes more frequently than in blondes, (b) Faulty dietary habits; habitual overeating, especially among those who lead an inactive life, and the habit of eating exclusively concentrated foods, such as milk, eggs and meat juices, which do not leave sufficient residue to provoke intestinal action. Also the overeating of food which leaves a great residue in the bowels, as the bulky vegetable foods, which are rich in cellulose and so distend the bowels as to produce a temporary, or in some cases persistent, paresis of the walls of the bowels; the drinking of liquids which contain tannin, such as tea and red wines, which exercise an astringent influence upon the glands of the intestinal tract and thus retard their action; the failure to drink plenty of water, a condition which becomes a habit with many patients and prevents proper liquefaction of the residues. Also the habitual taking of purgatives, (c) Atonic states, general and local, such as neurasthenia, hysteria, anemia and malnutrition, also induce it. It is caused by degeneration of the intestinal musculature; by chronic enteritis, especially ulcerative enteritis, which induces paresis; by glandular insufficiency and by diseases of the heart, liver and portal system. Faulty innervation of the intestines results in constipation, it being common in disease of the spinal cord and of the meninges.
A spastic condition of the bowels found in patients in whom nervous irritability is a pronounced symptom, and sometimes in the aged without known cause, gives rise to a very serious form of constipation. An atonic condition of the abdominal muscles from overstretching, as in frequent pregnancies: intra-abdominal tumors and obesity, also cause it. (d) Local painful conditions, as inflamed hemorrhoids, prostatitis, and a retroverted and inflamed uterus, may cause it. (e) Fecal accumulations, tumors, strictures and persistent neglect of the calls of nature are also to blame for its presence.
Symptomatology:—There are many patients who have two or three movements habitually each day, and who feel uncomfortable if they do not, while others evacuate the bowels only once in two or even three days, for years, and do not feel any inconvenience from it. The majority, however have discomfort and unpleasant sensations if defecation does not take place freely once each day. Debility, lassitude, low spirits, lack of mental vigor, headache, loss of appetite and occasionally vertigo are among the most common symptoms of constipation. The tongue is usually furred, the skin lacks clearness or it may appear anemic, or it may have a peculiar cast which is described as "muddy." Neuralgias are common, especially those of the sacral nerve, and migraine is undoubtedly dependent upon constipation in many cases.
There is no doubt that in some cases it may be caused by painful menstruation, while in other cases in women it will induce painful menstruation. A sense of pelvic pressure or fulness, sometimes attributed to disease of the uterus and appendages is frequently relieved by correcting the constipation. It is not uncommon in severe cases for the persistent fecal accumulations to cause hemorrhoids, ulcers of the colon, dilatation of the colon, perforation or intestinal occlusion. The sacculi may be filled with feces in an occasional case, but there may be a way chanelled between the hardened impacted feces and the intestinal wall through which liquefied feces may pass. Or there may be a chronic diarrhea with this impaction. In old persons enteroliths may be formed from calcification of these masses; sometimes doughy, tumor-like mases may be formed from them, or the mass may have a hardened or resistant feel, upon palpation. These are more apt to be found at the flexures of the colon or above the navel. Those patients who have constipation with occasional diarrhea frequently suffer from attacks of nausea and vomiting; or in the spastic type the feces are passed in ribbon or pencil-like portions, and in all cases the odor is exceedingly foul.
Prognosis:—The prognosis naturally depends upon the cause. The danger to life in the chronic cases is not great, but the condition induces a serious impairment of the health.
Treatment:—The habit of giving laxatives or physics for the cure of constipation is pernicious, and results in most cases only in an increase of the condition. The influence of drugs upon the condition as a whole is by no means as great as is commonly supposed. The important measures in the treatment are the adjustment of the environment and dietary conditions to the demands of the patient, and the proper arrangement of the general habits of living. All of this will require time, and patience and persistence are essential. Measures must be adopted to arouse the tone of the muscular structures of the intestines. This is accomplished to a very satisfactory degree by systematic massage, by kneading of the bowels, or by the use of vibration properly applied. This latter in a few cases will be found particularly efficacious. The use of electricity is an important addition to the treatment, especially in elderly cases or in those cases where there is a lack of nervous tone—imperfect innervation. The current must be selected and applied with reference to the condition of each patient. In some cases the galvanic current will be found of the greatest utility; in other cases the faradic current will be found superior.
Concentrated foods must be avoided, and the patient must acquire the habit of drinking an abundance of water which is not heavily charged with any of the calcium salts. It is a good plan for these patients to have a large glass of water brought to the bedside when they are first awakened in the morning, and to drink this cold, and immediately compose themselves, lying upon the right side, to another short nap. This will permit a large proportion of the water drunk to pass directly into the intestines, and will materially assist in the liquefaction of the feces. Upon rising it is a good plan to eat a fresh apple, or to take an orange at the beginning of the breakfast meal. Figs, dates and prunes are all accredited with laxative properties, and as long as they are taken will assist in overcoming the habits of constipation.
The patient should form the habit of going to stool regularly at the same time each day. The best time that can be selected for this is immediately after breakfast. In order to assist in the establishment of this habit an enema may be taken at the time the stool is desired, or a glycerin suppository may be introduced at this time, for a few days. Water should not be drunk at meal time, but should be drunk freely after the food is digested, and before another meal, in sufficient time to permit the larger portion of the fluid to pass from the stomach, into the bowels.
Among the remedies which may be used for chronic constipation by far the best in my experience is cascara sagrada, but to be efficacious it must be properly used. I believe that it may be laid down as a rule that the more time that is taken, within reasonable limits, to obtain an apparent beneficial influence from the remedy, the more perfect and satisfactory will be the result of its influence. I advise that the patient do not depend upon this remedy to move the bowels for the first week of its use, but that he use enemas, suppositories or other measures with which to procure a movement while waiting for the influence of the cascara. It should be begun in five drop doses of a good fluid extract, upon rising and retiring, twice daily, increasing the dose one drop each time, until the bowels move from the influence of the remedy. The dose given at that time may then be sustained for a day or two if the bowels move once each day. It may be found, if this dose is continued for several days, that it will produce two or more movements each day, which must not be permitted. The dosage should be reduced one drop at a time, but always giving enough to induce one movement only each day.
It will be found, after from fourteen to twenty days, that but very little if any of the remedy is needed; the bowels continue to move from the corrected habits of food and living. In other cases it will be necessary to give three, four or five drops twice a day for from thirty to forty days. In a very few cases the dosage named will be too small, while in other cases it will be larger than necessary; the agent, therefore, must be carefully adjusted to each case. It must be borne in mind that if a cure is desired from this remedy, it positively must not be given in sufficient strength to induce active movements at the start. This will interfere with or entirely prevent its permanent influence.
The custom adopted by many patients of depending upon the use of popular mineral waters is bad. The influence may seem to be satisfactory at first, but ultimately the condition is not found to be improved. The use of sodium phosphate, in half of a pint of cold water, upon rising in the morning, will for a short time be of material benefit to those who suffer from slight congestion or sluggish action of the liver. But this remedy should not be continued too long.
In cases of chronic constipation induced by temporarily existing conditions, such as that present during pregnancy, or that following severe surgical operations, I have used the following with very satisfactory results: Prepare a strong decoction of senna leaves by boiling one ounce of the leaves in sufficient water to make a pint of the decoction when thoroughly boiled. This is strained, the leaves rejected and the liquid put back into the vessel in which it was boiled, and to it are added as many good French prunes as may be well stewed in that quantity of liquid. They may be prepared as if for the table, the whole poured into a clean fruit jar and sealed. If one of these be eaten before each meal, this will correct the constipation, sometimes for a period of three or four months. At other times one of them may be taken twice a day, in conjunction with two, three or four drops of cascara sagrada, with good results. It is seldom that four each day will be needed.
In severely stubborn cases it is a good plan to inaugurate any course of treatment by high irrigation of the colon. This must be done very thoroughly, especially with patients of plethoric habit, who are somewhat inactive and who have a relaxed abdomen. These may need a repetition of the irrigation each week for three or four weeks.
