It is important to talk this matter over with patients; otherwise the true cause of their constipation may be missed. For instance, from the very beginning of human life an excess of fat acts as a lubricant of the intestine, and as a material by means of which other and more concentrated objectionable matter that needs to be eliminated is carried out with as little friction as possible. Mother's milk contains from one-fourth to one-third more fat than the baby can use in its economy. This is meant to furnish a lubricant for the large intestine. It is a residue that will aid in securing movements of the bowels at regular intervals.
Fats.—Many people who come to their physicians complaining of habitual constipation have been told, or have read, that fat is rather indigestible, and, as a consequence, they have eliminated from their dietary all fatty materials. Even butter they use but sparingly, and they exchange the cream in their tea or coffee for plain milk; they carefully remove as much as possible of the fat of meat and they abstain from all sauces in which fat is employed. Such practices make normal, natural, regular evacuations of the bowels extremely difficult.
Sugars.—Another food material that is a valuable aid to nature for the stimulation of peristalsis is sugar. In its digestion, a certain amount of fermentation takes place, and the gas from this stimulates peristalsis. Of course, there may be excessive fermentation, and then harm rather than good, is done. Ordinarily a certain amount of sugar is demanded by nature and practically all the food materials, even the meats, contain it. All the starches from vegetables have, as the end products of their digestion, various forms of sugary material. These are just the classes of foods that many nervous persons, suffering from constipation and anxious about their digestion, eliminate from their diet under the mistaken notion that they are indigestible, or are productive of undesirable fermentations. When they do so, it is not surprising that their constipation should be emphasized and that they should have to ingest other irritant materials, laxatives, to replace the sugars. It is probable that where constipation exists in the bottle-fed infant, the addition of a little brown sugar to the water with which the milk is diluted, is the safest and most natural way of correcting the sluggishness of the intestines.
Supposed Idiosyncrasies.—The physician will in many cases meet with the objection that some of these materials that he is recommending disagree with his patient. Most of the presumed idiosyncrasies in the matter of food are founded on extremely insufficient evidence.
Not infrequently young persons who are thin and inclined to be [{277}] constipated, and who need to take fats plentifully, do not care at all for butter. Sometimes this is founded on nothing more than the fact that at some time or other the butter provided for them was rather poor, and they got out of the habit of eating it. Now they assume that their disinclination is physiological. In this regard, as with milk, a little careful persistence will usually convince the person that there is no natural obstacle and no good reason why they should not partake, in moderate quantities at least, of this extremely valuable article of food.
Often the supposed idiosyncrasy against a food is due to no better reason than that on a single occasion it disagreed, owing to its preparation, the circumstances under which it was eaten, or the materials with which it was associated. An aversion, for instance, to so nutritious and so valuable a food-stuff as hog-meat will be acquired for no better reason than that fried ham or bacon disagreed with the patient on one or more occasions. Such people when told that ham, boiled so thoroughly that it crumbles in the fingers, is a favorite mode of giving meat to convalescents in European hospitals and that it agrees very well with them, will often be tempted to try it. Then they find they have been harboring an illusion as to their supposed idiosyncrasy for hog-meat. Nearly the same thing is true of bacon. A trial or two of crisp bacon, with the fat so thoroughly cooked out of it that it may be eaten out of the fingers without soiling them, will often convince those who doubt of their ability to eat it, how tasty a nutriment it is. Bacon is one of the most precious dietetic adjuvants in the treatment of constipation.
Exercise.—There is always a serious difficulty in the treatment of constipation in stout people. To counsel fats and starches and liquids in the quantities necessary to bring about regular natural movements of the bowels, through the mechanical presence of a sufficient amount of residue, will often add greatly to their weight. For them, exercises are needed. Not exercise in general, for many a man who takes abundant exercise may be constipated. I have patients with this complaint who are letter carriers, expressmen, even stevedores, and the like. The mere absence of a sedentary occupation will not guarantee against constipation. Motormen and conductors not infrequently suffer from it. What is needed particularly is exercise directed to the strengthening of the abdominal muscles, and the increase of peristalsis.
For this certain leg exercises that can be readily and easily done in less than five minutes each day will be found useful. A patient may be directed to lie on his back, lift up the leg as high as possible in the extended position, and do that with each leg an increasing number of times every day. At the end of a month he is able to lift each leg up forty or fifty times at each trial. This exercise twice a day, morning and evening, just before and after sleep, will usually relieve the constipation. The bringing up of the thigh on the abdomen as far as possible, not only acts as a sort of massage upon the abdomen itself, but the bellying of the large muscles within the pelvic and abdominal regions mechanically helps the movement of the intestinal contents. If, in addition to this, the patient gradually accustoms himself to rise to a sitting from a lying position, the constipation will almost invariably yield. In stout people, the presence of fat in the abdominal wall seems to weaken the muscles so that the intestines are not compressed as they should be in ordinary conditions, and peristalsis seems to be thus interfered with.
A heavy wooden (bowling) ball rolled on the surface of the abdomen, beginning low down in the right lower quadrant up towards the liver, across just above the umbilicus, and then down on the left is often advised. It is a good remedy but not better than the simple exercises of the leg and abdominal muscles suggested. The use of the ball has the advantage of novelty, and of distinctly adding to the suggestive value of the exercise treatment. It is particularly valuable for women. All of these exercises have a distinct value from their suggestive side. If thus twice a day for three minutes people are made to recall while doing the exercises the necessity for taking an abundance of fluid, forming a habit with regard to movements of the bowels and eating so as to encourage peristalsis, a definite good effect will be produced. In the treatment of stout people particularly, it is important to remember that the use of sufficient salt, and then of certain of the natural salts, as Carlsbad or Hunyadi Janos, may be of distinct advantage for their obesity. If taken regularly in small amounts, that is, just enough to help to a movement of the bowels, and if varied from time to time and occasionally interrupted while some other form of laxative is taken, much good may be done. It is as well to take simple irritants of this kind as some of the irritant foods that will have a tendency to add to their accumulation of fat, though they may increase peristalsis.