So-called Intestinal Auto-intoxication.—Those who are anxiously interested in the subject are likely to have read so much of intestinal auto-intoxications, of which a great deal has been written in recent years, that they will be quite sure the slightest delay in intestinal evacuation may be serious, or at least may profoundly disturb their economy. As a consequence, just as soon as the hour at which they should have a movement passes, they begin to worry about it. In a couple of hours they feel tingly all over, and they know that there most be poisonous substances in their circulation. After two or three more hours, they begin to have a headache. Then they have to give up work, and still more devote themselves to concentration of attention on the disturbed condition. Their sleep will be disturbed, perhaps will be delayed; they wake unrested and fearful of the awful effects of intestinal auto-intoxication. In most people this state of feeling is entirely due to suggestion.
So much has been said in recent medical literature of the influence of absorption of poisonous substances from the intestinal tract—the so-called intestinal auto-intoxication—that it is a surprise to learn how little we know, definitely and absolutely, about this subject, and how many theories have come and gone. Arthur Hertz, in his "Constipation and Allied Intestinal Disorders" (Oxford Medical Publications, 1909), reviews the whole subject very interestingly but shows that we are entirely without any definite conclusive evidence for what has been talked about so much. The idea had often occurred, and been expressed vaguely, in medical literature in the old time, but began to have its great vogue when the high-sounding Greek term copremia (literally "excrementitious-substances-in-the-blood") was invented, toward the end of the first quarter of the nineteenth century. Naturally this had a strong suggestive effect. Bouchard took it up a generation later, and then intestinal auto-intoxication, another mouth-filling term, came to occupy much attention as an explanation for various vague conditions, and especially nervous discomforts of many kinds. Bouchard's method of proving his theory by showing how much toxic material was reabsorbed from the intestines, using the urine for injection into animals, was open to many objections. Now it has been quite discredited.
Bouchard's disciples exaggerated and theorized even beyond their master, until intestinal auto-intoxication became the same sort of a refuge for the puzzled physicians of our time—like rheumatism or the uric acid diathesis, for those of a score of years ago. Various methods of demonstrating the toxicity of substances absorbed had a vogue for a time, but they have now lost their significance. There are only a limited number of people who seem to suffer [{271}] from the symptoms attributed to such reabsorption. Some people who are quite constipated have none of the symptoms at all, while a delay of an hour or two in the evacuation seems to affect other people very much. These latter are especially nervous persons. It now seems very clear that the liver acts as a safeguard against the absorption of poisonous materials from the intestinal tract, and that neither degenerate proteid materials, nor bacterial toxins, are allowed to affect the system to any serious degree. After all our study, as Dr. Hertz insists, we have as yet no evidence that poisons are absorbed.
Reassurance as an Element in Treatment.—The most important element in the rational treatment of constipation is to make patients understand that under ordinary circumstances the symptoms of auto-intoxication, of which so much is said, do not develop until there has been long-continued accumulation of excrementitious material and under conditions favoring absorption. Even then nature learns to protect herself against untoward conditions. We have some very striking examples of good health in spite of even very rare movements of the bowels.
Examples of Intestinal Tolerance.—There is the famous case of the French army officer who, from his earliest years, did not have regular movements of the bowels, but secured evacuations of them by artificial aid once every two months or more. He lived to the age of past fifty, and then died from an intercurrent disease not connected with his intestinal condition, having in the meantime enjoyed good health. He was able to accomplish his duties as an officer without any special allowances, and he was on the sick list much less than many brother officers whose intestinal condition left nothing to be desired. This remarkable man succeeded in doing his life work without his condition being known by others to any extent, and it was only inconvenience, and not serious illness, that he suffered from. After his death, it was found that certain folds of the lower bowel were so large as to meet across the lumen of the bowel, making shelves and pouches in which fecal material gathered, preventing the movement of all material above.
In the Orient, it is said that many people, especially of the better class, do not expect to have movements of their bowels every day. Some of them, indeed, do not encourage intestinal evacuations oftener than once a week, sometimes even more seldom. As their diet is more largely vegetable than ours, this is all the more surprising. This custom does not contribute to their good odor, but this they compensate for by using various Eastern perfumes. The average length of life of such people is not much below the Occidentals and the difference is probably accounted for to a great extent by other unhygienic practices, rather than this failure to have regular movements of their bowels. In the meantime, they do not suffer any particular inconvenience, and live life quite as free from the ordinary pains and aches as do the people of the West. Of course, in such cases the custom has been established early, and nature has grown accustomed to it. Nature seems to be able to stand almost anything, if she can only survive it long enough to neutralize its effects by some of her marvelous means of compensation.
A case under my observation some years ago deeply impressed upon me how thoroughly the human system can learn to get along in spite of extremely unfavorable conditions in the matter of intestinal evacuation. The case was that of a young woman suffering from some internal trouble and there was [{272}] a possibility of the growth of a tumor. Some charitable people had been interested in her case, and the question had arisen whether the tumor might not be physiological. Her story was a very curious one. She and her sister worked in a mill. They came from a family that had been reduced in circumstances, and were much more sensitive, as regards the decencies of life, than were their fellow workers. In order to get to the toilet, the working girls had to pass a window of an office where a number of men were at work. The other girls did not seem to mind it, but these two girls were so sensitive that they preferred not to use the toilet room at the factory. They had to leave home shortly after six o'clock in the morning. They did not get home until nearly seven. For a time, they succeeded in accomplishing their intestinal functions during the hours of their stay at home. Gradually, however, this habit was broken, and at first they went two or three days without an evacuation, then four or five days, and finally a week. It then became their custom to take a large dose of epsom salts on Saturday night and spend most of the day on Sunday getting rid of the accumulated excrementitious material of the whole week.
They taught Sunday School in the afternoons, and as the elimination of the accumulation of week-long material interfered with this, they gradually acquired the habit of doing their Sunday School work on alternate Sundays, each taking the other Sunday for evacuation purposes. It might be expected that this serious abuse of function would soon lead delicate girls, compelled to work full eleven hours a day, into rapid serious breakdown. But it did not. This state of affairs continued for more than a year. Then finally one Sunday, the more delicate of the two girls found it impossible to open her bowels at the end of two weeks, and though she stayed at home the next Sunday found it likewise impossible. Had not the directress of the Sunday School, who had become interested in them, succeeded in gaining their confidence, it is possible that they would not have consulted physicians even for some time longer, though about three weeks had passed without an evacuation.
Probably every physician in active practice has women patients who have been constipated for successive periods of three or four days at a time, for several months, without much disturbance of the general condition. While, then, there are many nervous persons who are quite sure that they begin to notice definite symptoms within a few hours from the failure to have a motion of the bowels at the time when they had been expecting it, it seems certain that this is generally rather the result of anxiety and nervous worry than consequent upon any actual absorption of toxic materials—intestinal auto-intoxication—as these patients, with a naïve liking for nice long names, find such satisfaction in describing their condition. A simple explanation of the complete lack of inconvenience that is found in so many cases of constipation, will neutralize the unfavorable auto-suggestion that exists, and make these people much less likely to suffer.
Individual Variation.—Another suggestive item of information that should be given those who are over-sensitive and anxious in the matter, is that different individuals vary very much in the need for intestinal evacuation. Perfectly healthy people have lived long and happy lives, having an intestinal evacuation only once every two days. Whether it may not in exceptional cases be rarer than this without serious injury, immediate or remote, [{273}] experience has not definitely settled. Many of these people with infrequent intestinal movements, have gone on utterly unconscious of the frequency or infrequency of the calls of nature, paying no attention at all to the matter until by some chance remark or a newspaper health item, it is brought forcibly to their notice. They have not had a symptom before of any kind, but now they begin to note all sorts of symptoms because they try to order their lives after the supposed rule that they have heard or read.