Anatomical Peculiarities.—On the other hand, some people normally have two evacuations a day, and seem to require them if they are to remain in the best physical condition. While daily evacuation is to be considered normal, individual departures from it in either direction must be respected as quite within the bounds of good health. Sometimes there are anatomical reasons, as the capacity of the large intestine. Sometimes there are physiological factors, as the amount of food taken, or the fullness or rapidity of function in the digestive tract.
Amount of Food as a Causative Factor.—Frequency, or infrequency, of bowel movements seems to depend to a great degree on the amount eaten. It is well known that two men of the same weight and doing the same work often seem to require quite different amounts of food to enable them to accomplish their tasks. This is what might be expected, since it holds true also for the consumption of fuel in heat machines. Engines built in exactly the same way often require quite different amounts of fuel in order to release the same amount of energy. Where men are large eaters, the amount of excrementitious material left will usually provoke, if not actually demand, more frequent evacuation than where the amount eaten is small. Variety of food also has an important bearing. Men who live largely on beef, milk, eggs and food materials that do not leave much residue, do not require, indeed they cannot have, frequent evacuations. Those who live almost exclusively on vegetables, with large amounts of residue, will require more frequent evacuation of the bowels. Certain other dietetic habits, as the amount of fluid taken with the meal, or whether food is eaten in the solid state or cooked into purees, stews and the like, make a decided difference, the reasons for which are obvious.
Habit in Treatment.—For the regulation of the bowels and the proper treatment of constipation in nearly all cases, more weight must be given to the directions laid down for the patient's attitude of mind and habits of life than to drug treatment. The patient must be made to realize that the directions given to him are much more important for the effective relief of his condition, than is the medicine prescribed. As a rule, medicine is meant only to afford relief from immediate inconvenience, in the hope that after a short time new habits will be formed which will remove the habitual constipation by correcting certain hampering conditions that have unfortunately become established.
Habitual Evacuations.—By far the most important element in the treatment is to make the patient realize that habit plays the largest role in the regular evacuation of the bowels. A child, even under two years, can, by tempting it at certain times to evacuate its bowels, be gradually brought to establish a habit that will save much inconvenience for nurses and the family. This has actually been done for most human beings now alive, and this same thing can be done at all stages of life. If a particular time be chosen, and the [{274}] individual habitually goes to the toilet at that time, results may be confidently expected. It is rather important that the time chosen be one when there is not much hurry nor anxiety, and when it is reasonably certain that the same time can be taken every day. It is surprising how much so simple a bit of advice as this will do for many people who have considered that they have been suffering great discomfort from habitual constipation. Between the persuasion that an occasional failure to have a movement is not serious and the definite habit of journeying to the toilet room at a particular time, whether the desire is felt or not, many cases of habitual constipation will disappear with, perhaps, only the necessity for the administration of such drugs as will prove laxative to a slight degree during the first two or three weeks.
Ingestion of Fluids an Important Influence.—After the suggestion of a habit and its extremely efficient influence, the most important idea that a patient suffering from constipation must be made to grasp, is the necessity for fluids. That there shall be easy movement of excrementitious material in the digestive tract, there must be fluid enough ingested to keep the residue, after digestion, thoroughly moist, so as not to allow it to become dry and compact. To secure this, a reasonable amount of liquids must be taken. So much has been said in recent years about the actual and possible harm of taking much fluid with meals, because of the danger of diluting the gastric juice, dilating the stomach and the like, that many persons who eat under the control of their reasons rather than their instincts, have very materially lessened the amount of liquids taken at meal time. This is undoubtedly one of the reasons why constipation has become more common in the last half century. In the olden time considerable quantities of fluid were taken at meals. With people in our time deliberately diminishing the quantity, there is often not enough fluid ingested to keep the human economy in proper working order. Prof. Hawk's work shows how utterly wrong was this limitation.
The ordinary excretion of water through the kidneys should be at least three pints, another pint is exhaled from the lungs—the quantity is even more than this in steam-heated houses where no provision for moistening inhaled air is made—and probably still another pint is needed for other purposes, perspiration, nasal and ocular secretion, and the like. Two quarts and a half to three quarts of liquid must be daily ingested then, and unless special care is taken to see that this amount is consumed the system may have to get on with much less, but as can readily be understood, not without difficulty. The ordinary glass of water does not contain half a pint; the ordinary tea cup probably holds not more than from four to six ounces. A glass of water and a cup of tea or coffee is about the limit of consumption of fluids at meals for ordinary people, and some take even less. Except in hot weather, comparatively few regularly take any fluids between meals. At the most, then, three or four pints of liquid is taken, instead of five or six, and the consequence is that the intestinal contents are deprived of their fluids by the call of the system for more liquids. Peristalsis has, therefore, to overcome the sluggish movement of the excrementitious material, which usually does not contain as much liquid as would make its movement easy and normal.
Residual Material.—The next most important consideration after the amount of fluid in the intestines, is the amount of the residuum which the lower bowel has to move. Evacuation of the intestines is to a great degree [{275}] a mechanical arrangement. When sufficient material is contained in the lower bowel, it pushes on ahead of it the matter that has been gathered there during the immediately preceding time, and so leads to an accumulation in the rectum that brings about reflex evacuation. It is only indigestible material that is thus excreted. If sufficient indigestible material is not taken with the food, there will not be sufficient residue left after digestion to call for the exercise of the evacuant function of the intestines, and the consequence will be sluggishness and failure to bring about daily movements. Originally nature provided food materials so arranged that the amount of indigestible material was sufficient for the exercise of peristaltic function; or rather perhaps, the regularity of peristaltic movement is of itself a development from the habits that were gradually formed in moving the residue that is normally left from food materials in the state in which they are produced by nature.
Food materials are no longer taken to any great extent in the form in which they are provided by nature. We have learned to eliminate the coarser indigestible portions. Bread used to be made of the whole wheat, and of rather coarse flour, leaving a large residue for peristalsis to exercise itself on. Now only fine white flour is used, leaving a minimum undigested. Vegetables used to be taken with much more waste material attached to them than is the case now. After being baked, potatoes were often eaten with the skins on, apples and other fruits were eaten unpared and many of the coarser vegetables, turnips, carrots, beets, and greens of various kinds that leave large proportions of waste were much more commonly used. Movements of the bowels depend on this residue. If it is not present the bowel movements will not take place with the regularity observed when food with more residue is consumed.
Diet.—Prof. Otto Cohnheim, in his lecture before The Harvey Society in New York, December, 1909, emphasized the necessity for a mixed diet. The less vegetables are taken, the less cellulose remains undigested to stimulate peristalsis. Liquids find their way through the intestines by a system of percolation, and do not excite peristaltic movements. Meat, if well digested, is almost entirely dissolved in the stomach and becomes a fluid. Vegetables are passed on to the intestines as a rather thick paste. Occasionally, in the midst of this paste there are portions of food of good size. Those excite peristalsis; hence the necessity for vegetables in the diet, if peristaltic movements and regular evacuations are to take place. This physiological law is poorly understood. Patients have heard so much about the indigestibility of starches, that whenever they have any uncomfortable feelings in their abdominal region, supposed to be due to indigestion, they commonly eliminate vegetables from their dietary with the consequence that their disturbed condition is likely to be emphasized rather than improved.
Limitation of Diet.—Just as soon as a patient's attention is attracted forcibly to any tendency to constipation, he is almost sure to conclude that this is a symptom of indigestion and he proceeds to put into practice all the rules which he has heard and read for the treatment of indigestion. The first of these is elimination from the diet of all indigestible food products, including most of the vegetables. The result is a vicious circle of cause and effect by which constipation is rendered worse than before. This needs [{276}] to be explained to intelligent patients in order to make them understand that some of the new habits which they have been forming and which they are prone to think highly hygienic, of cutting off all food containing indigestible material, are really important factors in the causation of further intestinal disturbance. It will often be found that the real reason for patients' inability to have daily evacuations of the bowels, is that they have become persuaded that various forms of food are either indigestible on general principles, or else are indigestible for them. For this reason they have eliminated from their diet most of nature's ordinary and quite natural provocations to intestinal evacuation, only to have to substitute artificial means to the same end in the form of the various laxatives.